COLUMBIA  LIBRARIES  OFFSITE 

HEALTH  SCIENCES  STANDARD 


HX64055817 
RD1 1 3  W22  1911     Piaster  of  Paris  and 


r!»?'«M^ 


•••J  H 


PLASTER 


BLJJd. 


w^^ 


/s// 

mtftfCttpofBfttig0rk 

CoUege  of  ^fjp£^in<ins!  anb  ^urgEons! 
Hibrarp 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/plasterofparishoOOware 


PLASTER    OF    PARIS 

AND 

HOW   TO   USE   IT 


BY 

^lARTIN  W.  WARE,  M.D. 

NEW  YORK 

Adjunct  Attending   Surgeon,    Blount   Sinai   Hospital;    Surgeon   to   the 

Good     Samaritan     Dispensarj';     Instructor     of     Surgery, 

The  New  York   Post   Graduate   Medical    School 


SECO-ND   EDITION.   REVISED   AND   ENLARGED. 
Illustrated  with  go  original   drawings. 


SURGERY    PUBLISHING    COMPANY 

92  WILLIAM  STREET 

NEW  YORK 

I9II 


Copyright,   1911 
By 
SURGERY  rUCLISHING  COMPANY 
New  York. 


PREFACE  TO  THE  SECOND  EDITION. 

The  exhaustion  of  the  first  edition  and  the  per- 
sistent demand  for  this  book  are  the  incentives  for 
this  second  edition. 

I  have  availed  myself  of  the  suggestions  pro- 
ferred  in  the  kindly  criticisms  of  the  reviewers  of 
the  original.  In  appreciation  thereof  much  has 
been  rewritten,  revised,  rearranged  and  numerous 
innovations  embodied. 

The  chapter  on  Plaster  in  Dentistry  has  been 
omitted  as  not  being  germane  to  the  work. 

The  illustrations  have  been  added  to  and  a  great 
number  of  new  ones  substituted. 

Aly  acknowledgements  and  thanks  are  due  to 
Dr.  Erwin  Reissman  for  the  execution  of  the  draw- 
ings ;  to  Dr.  Walter  ]\I.  Brickner  for  his  valuable 
advice  in  editing  this  book  and  to  Dr.  J.  ^lac- 
Donald,  Jr.,  for  his  encouragement,  support  and 
numerous  acts  of  courtesy  which  have  rendered 
possible  this  second  edition. 

]\I.\RTix  W.  Ware. 

2/  East  Sist  Street^  AVtc  York. 


l'Rl-:i  ACE  TO  Till'.  I'JkST  ICOITION. 

Tlie  material  for  the  subject-matter  of  this  be^ok 
is  based  on  ten  years'  dispensary  practice  in  the 
very  large  joint  disease  and  fracture  service  (5,000 
cases)  of  the  Good  Samaritan  Dispensary. 

The  embodiment  in  book  form  of  this  experience 
and  I  if  wliat  has  heretofore  been  but  a  fragmentary 
consideration  of  the  subject  is  due  to  the  sugges- 
tion of  Dr.  ^^'alter  M.  Brickner,  Chief  of  the  Surg- 
ical Out-patient  Department.  Mt.  Sinai  Hospital, 
whose  valuable  assistance  in  editing  these  pages  is 
herel)}'  thank  full  v  acknowledged.  Thanks  are  due 
to  Dr.  Maurice  Green  for  his  aid  in  the  preparation 
of  the  chapter  on  Plaster  of  Paris  in  Dental  Surg- 
erv.  The  illustrations  are  for  the  most  part  re- 
produced by  Dr.  Erwin  Iveissman  from  original 
photographs  and  sketches ;  others  from  standard 
text-books  of  surgery. 

]\L\RTiN  W.  Ware. 

iiqS  Lc.viiigto)!  Atcuuc, 

Dec,   1906. 


TABLE   OF  CONTENTS 


CHAPTER    I 

Pages 

The   Plaster  of  Paris   Bandage 1-20 

CHAPTER    II 

The    Application    of   the    Plaster    Bandage    to    In- 
dividual   Fractures    21-24 

CHAPTER    III 
Fractures   of  the  Upper   Extremity 25-32 

CHAPTER    IV 
Fractures   of  the  Lower   Extremity 33  5a 

CHAPTER    V 
Molded  Plaster  of  Paris  Splints 5^-64 

'  CHAPTER    VI 
Plaster  of  Paris  in   Orthopedic   Surgery 65-99 

V. 


LIST  OF  ILLUSTRATIONS 


FIG.  PACK 

1.  Preparing  plaster   baiulagc   by   liaml 2 

2.  Plaster  of  Paris  cradle 4 

3.  Calot  method  of  preparing  plaster  bandage 5 

4.  Plaster    bandage    and    manner    of    handing    it    to 

surgeon     6 

5.  Immersion    of   plaster    bandage y 

6.  Removal  of  frayed  ends  of  bandages  after  immer- 

sion       y 

7.  Illustrating   the    cuff   of    cotton    at    upper,    lower, 

limit    14 

8.  Strip  of  metal  incorporated  in   bandage 15 

9.  Dividing  cast  with   Gigli   saw 16 

ID.   Cast    removed    in    lateral    halves 17 

11.  Grooves  cut  with  niitrc  saw 18 

12.  Mitre  saw   i.S 

13.  Stilles  shears 19 

14.  Manner  of  removing  cast ..20 

15.  Reapplying   cast   with   adhesive   straps 20 

16.  Plaster  bandage  for  forearm 25 

17.  Shoulder   spica   for   humerus   fracture 27 

18.  Cast   for   lower   arm — elbow 28 

19.  Cast    for   forearm    or    wrist 30 

20.  /  'ri  u         • 

^  rhumb  spica   31 

22.  Posture  applying  cast   lor  hij)  fracture 34 

2;^.  Metal   hip  rest 35 

24.   Superimposed   fists   as   hip   rest 36 

3'     >  Extent  of  cast  for  hip  and  femur  fracture ^7 

27.  Application — hip   spica  in   suspension 38 

28.  Cast  for  fracture  of  upper  half  leg 39 

29.  Tricot  hose  investment  in  leg  fracture 39 

30.  Assistant   holding   foot   for  application   of   plaster 

bandage     40 

31.  Foot  held  at  right  angles  by  a  strip  of  bandage.. 41 

;i2.  Ambulatory   cast   for    leg   fracture 42 

;ji;ii.  Splitting  of  cast  to  obviate   pressure 43 

34.   Fenestrated  plaster  splint   44 

•5t.  Veneering  strips    47 

36.  "  "         48 

37-  "  "        48 

vi. 


LIST   OF  ILLUSTRATIONS. 

VIG.  PAGE 

38.  Metal    strips    to    bridge    two    sections    of    plaster 

bandage    4^ 

39.  Wire  worked  into  bandage  to  aid  suspension ...  .48 

40.  Molded  splint  with  wire  hooks 49 

41.  Suspended  fenestrated  cast   49 

42.  Spiral  and  concentric  folding  of  crinolin 51 

43.  ]\Iolded  splint  applied    S~ 

44.  Molded    splint    secured    b}^    bandage    while    hard- 

ening   5~ 

45.  Splint  lined  with  cotton 53 

46.  Yielded  splint  held  by  adhesive  plaster 54 

47.  Molded  splints  covered  with  bandage 54 

48.  ]\Iolded   splint  by  to   and   fro   passage   of   plaster 

roller  56 

49.  Two  pieces   of  flannel  for  Bavarian   splint 56 

50.  Posterior  molded  splint  for  humerus  fracture.  ..  .58 

51.  Molding  splint  for  humerus   fracture  with  roller 

bandage    59 

52.  Splint  suspended  to  dry   60 

53.  Braatz  spiral  molded  splint  for   CoUes   fracture.. 61 

54.  Cole's    sugar   tongue   splint 62 

55.  Molded  dorsal  splint  for  forearm  fracture 63 

56.  Plaster  of  Paris  gutter  splint  for  leg  fracture.  ..  .64 

57.  Crawling  posture  while  apphang  hose  investment 

for  jacket   65 

58.  Sayre's  suspension ' 66 

59.  Ladders  to  operate  suspension  apparatus 67 

60.  Shows  correct  and  incorrect  extent  of  plaster  for 

corset    69 

61.  Method    of    transporting    patient    with    jacket    or 

spica   70 

62.  Reposing  on  pillow  to  permit  jacket  to  dr}- 70 

63.  Trimming  jacket    y2 

64.  Finished    jacket    with    lacing    correct,      incorrect 

limits    y^ 

65.  Jury-mast  incorporated  in  jacket 74 

66.  Application — jacket  in  horizontal  position 75 

67.  Jacket  applied  in  hammock 76 

68.  Sling  suspension  to  apply  jacket yj 

69.  Bradford  frame 78 

70.  Corset  applied  in  frame 78 

71.  Corset  and  hip  spica 79 

72.  Plaster  crown   a   substitute  for  jury-mast 80 

73.  Lorenz  bed    80 

74.  Jacket  with   figure   eight   turns   of  neck   for   torti- 

collis    81 

75.  Plaster  of  Paris  collar 82 

76.  Plaster  coronet  with  ring  to  correct  torticollis.  .  .  .84 

77.  Calot  jacket — temporary  window 86 

78.  Calot   jacket — large   window S7 

vii. 


LIST  OF  ILLUSTRATIONS. 

iiG.  pa«;k 

79.  Fenestra  over  gibbus  in  Calot  jackt-t KS 

80.  Calot  jacket  for  upper  spine  disease 89 

81.  Calot  jacket  trimmed  for  upper  spine  disease. ..  .89 

82.  Method  of  walking  with  i)lastcr  hip  spica 90 

83.  Calot  jacket  and  liip  spica  combined gi 

84.  Wrong  plaster  cast  cutting  into  flesh q^ 

85-  "  "         "  "  ■'        "      93 

86.  Ankle  in  right  angle — cast  setting 04 

87.  Lorenz  unilateral  sjjica  for  congenital  hip  disease. 05 

88.  Bilateral    congenital    dislocation     corrected    with 

Lorenz  spica   97 

89.  Spica    for    congenital    dislocation    showing    e.xtent 

of  cast  and  abduction ; gS 

•  90.  Wolff's  metliod  of  correction  of  club  foot go 


vni. 


CHAPTER  I 


THE    PLASTER    OF    PARIS    BANDAGE 


Arabian  physicians  practicing  in  Spain  were  History 
amongst  the  first  to  utiHze  plaster  of  Paris  (gyp- 
sum) as  a  dressing,  but  credit  belongs  to  the  Dutch 
physicians  Mathysen  and  Van  der  Loo  (1852)  for 
having  invented  the  modern  plaster  of  Paris  dress- 
ing. (More  recently  it  is  stated  that  to  Kluge,  of 
Berlin,  1829,  belongs  the  priority  of  the  applica- 
tion of  plaster  to  fractures.) 

The  very  widespread  use  of  the  plaster  of 
Paris  bandage  in  hospital  and  dispensary  prac- 
tice for  purposes  of  fixation  and  immobiliza- 
tion of  fractured  bones  and  diseased  joints  is  in 
decided  contrast  to  its  limited  use  in  private  prac- 
tice. An  inquiry  into  the  reasons  therefor  finds 
its  best  answer  in  the  statement  that  the  plaster  of 
Paris  bandage  found  on  the  market  does  not 
usually  come  up  to  the  requirements.  Therefore  a 
description  of  what  constitutes  a  properly  made 
plaster  of  Paris  bandage  is  of  the  first  importance. 

The  plaster  of  Paris  used  in  the  making  of  the 
bandage  should  be  of  the  superior  quality  used  by 
dentists,  and  the  quick-setting  kind  is  to  be  pre- 
ferred. It  is  sold  packed  in  tin  cans  to  prevent 
deterioration  (hydration)  by  absorption  of  water 
from  the  air ;  and  for  a  like  reason  it  must  be 
stored  in  places  free  from  moisture  when  once  the 
original  package  has  been  opened.  Furthermore 
the  hand  or  receptacle  introduced  into  the  plaster 
should  be  absolutely  dry.  If  such  hydration  has 
taken  place  it  may  be  recognized  by  the  gritty  par- 
ticles in  the  plaster. 


Materials 


2      PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

Any  one  of  a  number  of  different  fabrics  may 
be  employed  as  a  substratum  in  preparing  the  band- 
age, such  as  gauzes,  criiiolin  (gauze  impregnated 
with  starch),  dextrine  gauze  and  flannel. 

The  use  of  plain  gauze  or  muslin  is  undesirable 
because  the  mesh  is  so  close  that  the  plaster 
comes  to  lie  on  this  fabric  and  hence  the  plaster 
sets  very  rapidly,  and  a  bandage  so  prepared  be- 
comes too  brittle.  On  the  other  hand,  a  gauze  too 
rich  in  starch  or  dextrine  will  wholly  prevent  the 
plaster    from    setting.     The    mesh    of    the    gauze 


Fig.    I.     Preparing  plaster  bandage  by  hand. 

should  be  28x32  threads  to  the  square  inch.  The 
best  kind  of  gauze  is  white  crinolin  without  cross- 
bars,"''•'  such  crinolin  as  is  used  by  milliners  and 
dressmakers.  If  the  crinolin  be  found  too  rich 
in  dextrine  the  latter  may  in  part  be  removed  by 
immersion  in  water  for  a  variable  time  and  then 
allowed  to  dry  before  incorporating  the  plaster. 
Manufacture  of  The  superior  plaster  of  Paris  bandage  is  inade  by 
the  Bandage  hand,  for  the  reason  that,  made  in  this  way,  the 
right  quantity  of  plaster  can  be  incorporated  in  the 
bandage.      The    crinolin    is    cut  into  strips  of  the 

•Crinoline    can    be    purcliased    wholesale   at    Adams    Mfg.    Co.,    106 
Grand   Street,   New  York   City. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT      3 

widths  desired,  and  loosely  rolled  in  ten-yard 
lengths.  One-quarter  of  a  yard  at  a  time  being-  un- 
rolled, a  handful  of  plaster  of  Paris  is  rubbed  into 
the  gauze  with  the  palmar  surface  of  the  fingers,  so 
that  all  excess  of  plaster  passes  to  either  edge  of  the 
bandage.  (See  Fig.  i.)  No  more  plaster  should 
be  rubbed  into  the  dextrine  gauze  than  the  meshes 
will  hold,  and  as  each  successive  yard  is  incor- 
porated with  the  necessary  quantity  of  plaster  it  is 
loosely  rolled  in  such  manner  that  in  the  center 
of  the  bandage  there  is  a  hollow  cylinder  of  the 
thickness  of  the  finger,  and  the  concentric  layers 
are  easily  movable  on  one  another.  This  arrange- 
ment permits  the  rapid  and  uniform  spread  of  the 
water  through  the  bandage,  and  prevents  parts  of 
the  bandage  from  being  insufficiently  moistened.  To 
guard  against  unraveling,  a  pin  should  be  inserted 
in  the  last  turn  which,  however,  ought  to  be  re- 
moved immediately  before  immersing  the  bandage 
in  water. 

The  completed  bandages  should  be  placed  on 
end  and  sealed  in  individual  tins  in  the  bottom 
of  which  a  small  quantity  of  plaster  of  Paris  is 
placed,  or,  likewise  arranged  on  end,  they  may 
be  packed  in  bulk  in  large  tin  containers.  If 
the  plaster  cannot  be  stored  in  a  dry  place,  it  is 
advisable  to  wrap  each  bandage  in  wax  paper  or 
gutta  percha  tissue,  newspaper  also  answers,  and, 
in  any  case,  it  is  a  wise  precaution  to  seal  the  can 
with  a  strip  of  adhesive  plaster,  passed  about  the 
overlapping  e:'ge  of  the  cover.  The  individual 
tins  or  tin  containers  protect  the  bandages  from 
moisture,  and.  furthermore,  permit  them  to  be 
placed  in  ovens,  as  a  preliminary  to  using  them,  in 
order  to  drive  off  any  moisture. 


Storage 


4      PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

Bandages  of  The  disadvantages  common  to  the  plaster  of  Paris 
Commerce  bandages  of  the  shops  are  that  the  fabric  is  not  of 
the  dextrine  order;  the  mesh  is  too  closely  woven — 
the  plaster  lies  on  the  bandage  instead  of  in  the 
meshes — and  as  a  consequence,  there  is  an  excess 
of  plaster ;  the  bandages  are,  as  a  rule,  so  tightly 
rolled  that  the  water  does  not  reach  the  deeper  lay- 
ers. These  are  tlie  bad  features  of  the  machine- 
made  bandage.  It  is  manufactured  by  dragging  the 
strip  of  muslin  through  a  compartment  (Fig.  2) 
filled  with  plaster  of  Paris,  and  winding  it  upon  a 
wiuiUass.     To  some  extent  a  bandage  of  the  sliohs 


Fig.  2.     Plaster  of  Paris  cradle. 


can  be  rendered  fit  for  use  by  rerolling  it  loosely  and 
in  this  aet  getting  rid  of  the  excess  of  plaster — 
before  immersion  in  the  icafer. 

[A  very  rigid  plaster  of  paris  bandage  (Euro- 
pean manufacture)  has  recently  been  put  on  the 
market.  It  is  made  of  exceedingly  fine  flexible 
aluminiun  broncc  zvire  netting  and  is  sold  in  widths 
of  one  and  one-half,  two  and  one-half,  three  and 
one-half  and  four  inches,  in  four-yard  lengths.  It 
is  applied  in  the  same  nianner  as  the  regulation 
plaster  bandage.] 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT      5 


Calot  believes  that  any  of  the  aforesaid  methods 
of  incorporating  plaster  of  Paris  (dry)  with  the 
crinolin  fabric  before  use,  causes  the  plaster 
bandage  to  deteriorate.  He  therefore  holds  the 
crinolin  bandages,  rolled  in  desired  lengths,  in 
readiness  for  immersion  in  a  plaster  cream  (3 
parts  water,  4  parts  plaster)  in  which  they  are  un- 
rolled and  rerolled  immediately  before  use.  (Fig.  3.) 

A  form  of  plaster  dressing,  well  adapted  to  the 
making  of  molded  splints,  can  be  obtained  by  dip- 


Calot 

Plaster 

Bandages 


Fig.  3.      Calot  method  of  preparing  plaster  bandage. 


ping  strands  of  hemp  jute  (Beeley),  flax  or  straw, 
of  about  the  width  of  the  finger,  in  a  cream  of 
plaster  of  Paris.  This  is  by  far  the  cheapest  form 
of  plaster  of  Paris  dressing.  Cotton,  impregnated 
with  plaster  of  Paris  and  placed  in  seamless  sacks 
of  tricot,  constitutes  another  method  of  making 
molded  splints  (Breiger).  A  modification  of  the 
Beeley  hemp  splints  consists  in  placing  into  a 
sheath  of  tricot  or  the  leg  of  a  stocking,  a  bundle 
of  thoroughly  beaten  hemp  strands,  steeped  in 
plaster  cream.     This  sausage-shaped  mass  is  thor- 


6      PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 

oughly  kneaded  and  molded  to  the  parts  (Turner). 
Other  fabrics  like  sail-cloth,  which  contain  sizing 
material,  are  also  useful  for  making  molded  splints; 
and  I  have  found  the  fabric  known  as  "Deimel 
linen  mesh"  suitable  for  making  molded  plaster  of 
Paris  splints  and  by  no  means  to  be  forgotten  and 
as  fundamental  in  plaster  technique  is  the  use  of 
large  sheets  of  crinoline  folded  on  several  layers, 
three  generally  suffice.  Sheets  of  woven  wire 
made  to  conform  to  the  parts  may  subsequently  be 
covered  with  a  few  turns  of  a  plaster  bandage. 

Before  starting  to  apply  the  bandage,  the  surg- 
eon and  his  assistant  should  be  properly  gowned. 


Fig.   4.     Plaster  bandag?   and   manner  of  handing  it  to   surgeon. 

In  every  instance  the  forearms  should  be  bared,  so 
as  to  permit  the  greatest  freedom  of  motion  in  ap- 
plying the  bandage.  To  protect  the  clothing  from 
being  soiled,  a  rubber  apron  or  gown  should  be 
worn  (Fig.  4),  or  the  latter  may  be  improvised 
from  a  bed-sheet.  Either  one  should  extend  to 
the  collar,  and  it  should  be  sufficiently  long  to  cover 
the  feet,  or  a  pair  of  rubbers  should  be  slipped 
over  the  shoes. 

■  In  private  practice  especially  it  is  also  necessary 
to  protect  the  surroundings  from  soiling  by  the 
plaster  of  Paris.     The  floor,  the  patient's  body,  and 


The  Immediate 
Preparation  of 
the  Bandages 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT      7 

the  couch  or  table  on  which  the  patient  is  placed 
should  be  covered  Avith  muslin,  gunny  sacks,  bed- 
sheets  or  a  rubber  sheet.  When  these  are  not 
available,  tar  paper,  newspaper,  or  ordinary  wrap- 
ping paper  will  serve  the  purpose.  It  should,  how- 
ever, be  borne  in  mind  that  if  a  properly  made 
bandage  is  used  which  is  squeezed  to  the  extent  of 
ridding  it  of  superfluous  water,  no  drippings  will 
be  scattered  and  the  whole  procedure  of  the  ap- 
plication of  the  plaster  differs  in  no  way  from 
simple  bandaging  and  no  soiling  of  the  surround- 
ings will  follow. 

The  number  of  bandages  intended  for  use  should 
be  removed  from  the  tin  container  and  stood  upon 
end  within  a  foot  of  the  vessel  holding  the  water 
in  which  they  are  to  be  immersed.  The  tin  con-  -p^^  Use 
tainer,  uncovered,  is  to  be  within  arm's  reach,  in 
case  necessity  arise  to  use  .more  bandages.  The 
bandages  to  be  used  are  to  be  placed  to  the  right 
and  the  container  to  the  left.  This  arrangement 
guards  against  particles  of  water  being  spattered 
upon  the  bandages  still  in  the  container,  rendering 
them  unfit  for  subsequent  use. 

The  vessel  in  which  the  bandages  are  to  be  im- 
mersed should  be  deep  enough  to  accommodate  the 
widest  bandage  vertically.  But  one  bandage  at  a 
time  should  be  immersed.  It  is  to  be  placed  end- 
zvise  in  the  vessel,  which  contains  water  as  hot  as 
the  hand  will  tolerate.  The  bandage  must  be  com- 
pletely submerged,  and  it  should  remain  so  until 
the  bubbles  cease  to  come  oiT.  (Fig.  5.)  This  will 
take  place  most  readily  in  the  very  loosely  rolled 
bandages.  The  tightly  rolled  bandages  obtained  in  the 
shops  should  therefore  be  unrolled  and  rendered 
loose  before  they  are  wet.     When  the  bubbling  has 


8      PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

ceased,  the  bandage  is  lifted  out  of  the  vessel,  and 
squeezed  with  the  hand,  merely  to  free  it  of  the 
excess  of  water.  In  some  bandages  the  edge  of  the 
crinoline  frays  out,  and  becomes  so  entangled  as  to 
hinder  the  free  unrolling  of  the  bandage.  To  pre- 
vent this,  the  frayed  out  ends  should  be  plucked 
from  each  side  before  starting  to  apply  the  bandage. 
(Fig.  6.)  After  the  bandage  has  become  limpid 
from  soaking  it  is  often  difficult  to  find  the  en«i, 
wherefnr  it  is  advisable  to  leave  a  short  lens^th  of 


Immersion    of   plaster   bandage. 


the  bandage  hang  over  the  edge  of  the  vessel  at  the 
moment  of  immersion. 

To  obviate  a  loss  of  plaster  from  the  w^et  bandage, 
Frieberg  recently  recommended  wrapping  each  band- 
age in  filter  paper  or  the  equally  pervious  Japanese 
paper  napkins  and  with  this  wrapper  the  bandage 
is  placed  in  water  and  allowed  to  remain  till  bubbling 
ceases.  With  the  wrapper  in  situ  the  bandage  is 
removed  from  the  water  and  squeezed.  Water  es- 
capes but  not  so  the  plaster.  Consequently  each 
bandage  is  richer  in  plaster  and  fewer  bandages  have 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT     g 


to  be  used.  Hence  Frieberg  regards  this  method 
an  economical  one  for  institutions  using  much 
plaster. 

To  hasten  the  setting  of  the  bandage,  some  manu- 
facturers recommend  the  addition  of  salt  or  alum  to 
the  hot  Avater.  This  is  not  advantageous  inasmuch 
as  the  bandao"e  often  sets  in  the  hand  before  it  is 


Chemical 
Ajuvants 


Fig.    6.     Removal    of   fraj'ed    ends    of   bandage    after   immersion. 

unrolled.  With  the  home-made  bandage  prepared, 
as  previously  described,  with  the  best  quick-setting 
plaster,  the  addition  of  chemicals  to  the  water  is 
superfluous.  Hot  water,  as  opposed  to  cold,  facil- 
itates setting. 

The  skin  has  to  be  protected  from  the  plaster  of 
Paris.  This  may  be  accomplished  in  various  ways. 
The  area  to  be  encased  in  the  plaster  of  Paris  band- 


Protection 
of  the  Skin 


lo   PLASTER  OF  P.IRIS  .IXP  HOW  TO  USE  IT 

age  may  be  wrapped  in  cotton  wool.  The  draw- 
back to  this  is  that  the  cotton  becomes  "caked"  and 
the  bandage  subsequently  loosens.  Better  than  this 
is  the  use  of  a  flannel  bandage,  or  the  "ideal  band- 
age,'" which  is  to  be  applied  smoothly,  zmthout 
X\.'ruiklcs  and  without  rci'crscs,  for  these  are  apt 
to  exert  pres.sure  on  the  soft  parts  beneath  when 
the  weight  of  the  plaster  is  brought  to  bear.  An 
elegant  investment  of  the  skin  is  afforded  by  the 
use  of  seamless  tricot  hose,  which  can  be  had  in 
various  widths  at  instrument  shops  and  is  applic- 
able to  the  trunk  or  extremities.  For  the  latter  a 
comfortably  fitting  sock,  stocking,  glove,  under- 
shirt sleeve  or  drawer  leg  may  be  used.  When  the 
plaster  bandage  is  applied  to  serve  as  a  cast,  the 
limb  need  merely  be  anointed  with  vaseline. 

,,...•  J        No  undue  traction  should  be  made  in  applying  the 

>plication  and  i  i  j     o 

successive  turns  of  the  bandage.  The  use  of  any 
other  than  a  light  hand,  when  unrolling  the  bandage 
on  to  the  member,  will  be  followed  by  such  con- 
striction of  the  limb  and  interference  with  circula- 
tion, with  the  setting  of  the  plaster,  that  its  prompt 
removal  will  probably  be  recjuired.  The  plaster 
should  be  applied  spirally,  yet  free  from  any  re- 
verses ;  where  a  reverse  might  be  encountered  the 
bandage  should  be  at  once  cut  and  a  beginning 
made  anew.  The  matter  of  reverses  with  plaster 
of  Paris  bandages  holds  good  only  for  the  plaster 
bandage  in  the  first  layers  where  such  folds  would 
exert  pressure.  About  the  outer  parts  of  the 
bandage  they  might  add  strength  though  none 
towards  the  appearance  of  the  bandage. 

To  give  strength  to  a  plaster  bandage,  to  avoid 
its  pressure  and  to  obviate  reverses,  it  has  been 
suggested  to  alternate  the  direction  of  the  spirals 


Precautions 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    ii 

by  standing  first  towards  the  head  and  then 
towards  the  foot  in  making  the  successive  layers. 
Thus  one  set  of  spirals  will  pass  from  right  to  left, 
the  other  from  left  to  right.  Such  refinement  I 
judge  to  be  impracticable  and  uncalled  for. 

In  fractures,  if  the  swelling  be  very  marked,  it 
there  be  evidence  that  the  extravasation  has  not  at- 
tained its  maximum,  the  limb  should  be  elevated 
and  subjected  to  the  compression  of  a  rubber  band- 
age, and  this  should  be  followed  by  gentle  massage, 
before  the  plaster  bandage  is  applied.  On  the 
other  hand,  it  should  be  borne  in  mind  that  usually 
several  hours  elapse  after  the  injury  before  the 
surgeon  has  been  called  and  has  made  preparations 
to  apply  the  plaster,  and  generally,  therefore,  there 
need  be  no  dread  of  an  increased  swelling  beneath 
the  bandage.  Indeed,  the  best  means  of  limiting 
the  swelling  after  a  fracture, is  the  prompt  applica- 
tion of  a  plaster  of  Paris  bandage.  If  there  be 
any  concern  that  the  plaster  bandage  has  set  too 
tight,  or  will  do  so,  this  may  be  remedied  in  the 
following  manner :  While  the  plaster  is  yet  soft, 
cut  through  the  entire  length  of  the  bandage  with 
a  penknife,  and  with  the  bandage  shears  also  divide 
the  bandage,  cotton  or  tricot,  underneath.  The 
subsequent  contraction  of  the  plaster  in  the  act  of 
hardening  will  cause  a  further  widening  in  the  fur- 
row made  with  the  penknife,  and  thus  relieve  the 
pressure  existing.  In  fact,  where  the  circum- 
stances are  such  that  the  bandage  cannot  be  in- 
spected within  the  first  twenty-four  hours  after  its 
application,  it  should  always  be  the  practice  to 
divide  the  plaster  as  described,  in  order  to  forestall 
any  possible  unpleasant  developments. 

To  guard  against  a  loosening  of  the  plaster  of 


12    PLASTER  OP  PARIS  AND  IIOJV  TO  USE  IT 

Paris  bandage,  as  the  furrow  widens,  strips  of  ad- 
hesive plaster  may  be  drawn  across  the  gap  to 
Hmit  it,  and  then  a  stout  muslin  bandage  applied 
over  the  whole  plaster  dressing.  Some  days  later, 
when  the  bandage  no  longer  adjusts  itself  to  the 
underlying  parts,  because  the  swelling  has  sub- 
sided, the  adhesive  strips  may  be  drawn  tight 
enough  to  obliterate  the  furrow  and  make  the  band- 
age fit  snugly. 

Marked  bony  prominences  that  have  to  be  cov- 
ered by  the  plaster  should  be  protected  with  a  layer 
of  non-absorbent  cotton  before  applying  the  flannel 
bandage  or  tricot  hose.  As  each  successive  turn 
of  the  plaster  bandage  is  applied  it  should  be 
smoothed,  always  in  the  same  direction,  by  friction 
of  the  hand,  moistened  occasionally  with  water. 
If  the  bandage  be  properly  made,  at  no  time  is  it 
necessary  to  rub  in  any  loose  dry  plaster,  or  any 
paste  of  plaster  that  settles  in  the  vessel.  In  fact, 
this  excess  of  plaster,  when  it  sets,  adds  unneces- 
sary weight  to  the  bandage,  and  lying  between  the 
layers  of  gauze,  as  it  does,  and  not  incorporated 
with  the  fibre,  it  renders  the  dressing  brittle.  The 
outer  layers  of  the  plaster  bandage  are  apt  to  chip, 
and  these  loosened  particles  irritate  the  skin  and 
soil  the  garments  and  surroundings.  To  obviate 
this,  the  finished  plaster  of  Paris  dressing  should  be 
covered  the  day  after  it  is  applied  with  a  single 
layer  of  dextrine  bandage,  which  is  moistened  and 
made  limp  before  it  is  applied,  but  soon  becomes 
dry  and  hard  again.  Where  a  tricot  is  used,  par- 
ticularly in  the  case  of  a  plaster  jacket,  the  tricot 
should  be  twice  the  length  of  the  me.nber  to  be 
invested  in  plaster.  The  excess  of  tricot  may  then 
be  drawn  over  the  finished  plaster  bandage  and  the 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    13 

two  edges  of  the  tricot  sewn  together  at  the  upper 
limit.  Such  a  finish  prevents  the  plaster  anywhere 
coming  in  contact  with  the  clothing. 

By  applying  a  coat  of  shellac  to  the  dried  plas- 
ter bandage  it  is  rendered  waterproof,  less  brittle 
and  obviously  more  durable. 

The  plaster  of  Paris  bandage  may  be  applied  to 
a  member  in  continuity  or  in  sections.  In  the 
former  method,  the  bandages  are  wound  spirally 
up  and  down  the  length  of  the  limb  without  re- 
verses until  each  roll  of  bandage  is  exhausted,  and 
a  number  of  bandages  is  used  to  cover  the  same 
ground  until  all  parts  are  sufficiently  covered.  In 
the  latter  method,  the  limb  is  divided  off  into  seg- 
ments and  each  segment  is  separately  invested  with 
one  or  two  bandages,  according  to  requirements ; 
each  section  of  plaster  overlapping  the  adjoining 
one.  The  former  method,  provides  a  stronger 
dressing. 

The  finished  bandage  should  be  exposed  to  the 
air  to  effect  a  thorough  hardening.  When  a  hot 
air  apparatus  is  at  hand  the  whole  member  may 
be  baked  for  one-half  hour. 

The  upper  and  lower  limits  of  the  plaster  band- 
age must  not  extend  beyond  the  bandage  enveloping 
the  skin.  An  elegant  finish  may  be  given  to  the 
edges  of  a  plaster  dressing  by  turning  over  its 
ends,  in  cuff-like  fashion,  the  ends  of  the  flannel 
bandage.  This  device  must  be  borne  in  mind  while 
the  plaster  is  being  applied,  so  that  the  final  turns 
of  plaster  at  either  end  may  securely  hold  in  place 
the  retroverted  fold  of  flannel  bandage.  Equally 
efficient  in  preventing  the  ends  of  plaster  from  im- 
pinging on  the  skin  is  a  cuff  of  cotton  held  in  the 
grasp  of  the  last  turns  of  plaster  at  either  end. 
(Fig.  7.) 


14    PLASTER  OF  PARIS  AND  IIOW  TO  USE  IT 

W'hen  the  tiexurc  of  a  joint  is  encroached  upon  by 
the  plaster,  a  cresu'cntic  section  may  have  to  he  re- 
moved from  the  latter  in  order  to  allow  free  motion 
of  the  joint.  This  had  better  be  done  with  a  sharp 
pen-knife  or  scalpel  drawn  over  the  bandag^e  while 
the  dressing  is  in  the  plastic  state,  .\gain,  with 
the  bandage  in  the  plastic  state,  it  can  be  molded 
by  the  pressure  of  the  finger  and  hands  with  mas- 
sage-like motions,  to  conform  it  to  the  contour  of 
the  limb.  To  bring  about  an  adaptation  this  mold- 
ing is  far  superior  to,  and  less  dangerous  than,  the 


Fig.    7.       Illustrating    the    cuff    of    cotton    at    the    upper    and    lower 
limits  of  the  plaster   of  Paris  bandage. 


employment  of  traction  on  the  plaster  bandage.  It 
is  most  desirable  to  exert  every  precaution  to  place 
a  plaster  bandage  correctly  in  the  first  instance. 
For  its  immediate  removal  in  recent  fractures  is 
a  painful  procedure  in  contrast  to  the  removal  in  a 
chronic  joint  affection,  or  some  weeks  after  frac- 
ture is  in  process  of  healing. 
Toilet  After  Such  plaster  of  Paris  as  may  have  been  spat- 
Bandage  is  tered  on  clothing,  carpets  or  fabrics  had  best  be 
Completed  allowed  to  dry  thoroughly  before  an  attempt  is 
made  to  remove  it.  The  spots  on  furniture  or 
wood-work  had  best  be  removed  while  moist,  or  if 
dry,  they  should  be  moistened.  If  not  much  time 
has  been  consumed  in  applying  the  plaster  of  Paris 
bandage,   and  the  plaster  on   the   surgeon's   hands 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    15 

is  still  moist,  it  can  be  readily  washed  off  in  warm 
running  water.  If  it  be  dry,  however,  friction  of 
the  hands  with  granulated  sugar  will  speedily  dis- 
solve the  plaster.  Friction  with  salt  will  effect  a 
speedy  removal  by  rendering  the  plaster  more  brit- 
tle, and  the  same  may  be  said  of  ablutions  with 
bichloride  of  mercury. 

The   discarded  portions  of  plaster  bandage  and    ^j^p^f^gg 
excess   of  loose  plaster  should  be  cast  away  with 
household  refuse.     The  water  used  for  immersing 
the  bandages  should  be  decanted  from  the  plaster 


Fig.    8.     A    strip    of    metal    one-half    inch    wide    incorporated    in    the 
bandage. 

paste  at  the  bottom  of  the  vessel  and  emptied  into 
a  sink  or  privy,  which  is  then  to  be  flushed  with 
hot  water,  preferably  from  the  tap.  Under  no  cir- 
cumstances should  the  paste  from  the  vessel  be 
emptied  into  the  waste-pipe,  sink  or  privy,  for  it  is 
likely  to  choke  it  up.  The  paste,  if  immediately 
attended  to,  may  be  loosened  by  shaking  the  vessel 
or  by  imparting  a  smart  blow  to  it.  If  this  does 
not  suffice,  or  if  the  vessel  be  porcelain,  the  ad- 
herent masses  may  be  lifted  or  scraped  off  with  a 


1 6    PLASTER  OF  P.IRIS  .IND  HOW  TO  USE  IT 


lemoval  of  the 

Plaster 

Bandage 


piece  of  wood  or  broken  up  with  a  knife.  The  ad- 
dition of  water,  hot  preferably,  will  aid  in  loosen- 
ing the  plaster.  The  whole  mass  is  to  be  thrown 
away  with  other  household  refuse  or  to  be  in- 
cinerated in  a  furnace. 

Some  deem  it  expedient  to  place  a  strip  of  zinc 
one-half  inch  wide  (Fig.  8),  or  a  wire,  on  the  limb 
before  starting  the  plaster  bandage,  and  to  allow 
the  metal  ends  to  protrude  as  a  guide  wdiere  to 
start  cutting  the  bandage.     The  metal  beneath  is 


Fig.    9.     Illustration    of   method    of    dividing   plaster    cast    with    Gigli 
saws    placed   under   the    bandages. 

to  guard  the  skin  against  being  cut  by  strokes  of  the 
knife.  It  has  al.-o  been  recomniended  to  place  a 
Gigli  saw  along  the  front  and  back  of  the  limb 
next  to  the  flannel  bandage  (Fig.  9)  before  apply- 
ing the  plaster  bandage.  To  the  protruding  ends 
of  the  saw  metal  handles  are  to  be  attached,  and 
with  the  aid  of  these  the  w'ire  is  set  in  motion  and 
the  plaster  divided    from    beneath.     Even  though 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    17 


this  saw  is  constructed  of  aluminum  bronze  it  is 
liable  to  corrosion  and  does  not  work  freely.  To 
offset  this  disadvantage  a  well  greased  silk  thread 
may  be  substituted  for  the  wire.  Eventually  the 
wire  saw  may  be  guided  along  the  thread.  Such 
a  wire  works  well  along  straight  lines  but  not  ef- 
fectively about  angles.  It  is  possible  with  two 
properly  placed  wires  saws  at  the  front  and  back 


Fig.    10.     Plaster    of    Paris    cast    removed    in    lateral    halves,    having 
been   cut    through    front    and   back   with    Gigli    saw. 

to  divide  the  cast  into  lateral  halves.  (Fig.  10.) 
If  it  is  the  intention  to  utilize  the  plaster  of 
Paris  bandage  again,  care  must  be  taken  to  pre- 
serve its  integrity  during  its  removal.  This  can  be 
best  accomplished  by  cutting  a  furrow  (Fig.  11) 
into  the  plaster  in  its  entire  length  with  a  penknife, 
cr,   more    expeditiously    performed,    with    a    mitre 


iS    PLASTER  OF  PARIS  AND  IlOW  TO  USE  IT 

saic.  (l''ig.  12.)  The  investing  fabric  l)eneath  the 
plaster  constitutes  an  impediment  to  the  free  mo- 
tion of  the  saw  and  therefore  gives  indication  when 
the  plaster  is  divided,  and  thus  prevents  injury  to 
the  soft  parts  beneath.  When  the  penknife  is  used, 
the  dropping  of  acetic  acid  (vinegar)  or  applying 
the  same  with  a  brush  on  the  plaster,  along  the 
path  of  the  knife,  will  lighten  the  otherwise  irk- 
some task. 


^^^ 

%-jn: 

41 

1 

i 

Fig.     II.      Showing    tiie    grooves    cut    in    the    plaster    cast    with    the 
mitre   saw. 


Fig.    12.      Mitre   saw. 


All  complicated  devices  of  the  circular  saw  for 
the  removal  of  the  plaster  are  useless,  as  the 
mechanism  becomes  blocked  with  particles  of  plas- 
ter. A  mitre  saw  works  quickly  and  with  some 
practice  corners  and  angles  can  be  gotten  around 
very  easily  by  using  the  heel  or  toe  of  the  saw. 
(Fig.  12.) 

A  very   effective   instrument,  for   cutting   a   fur- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    19 

row  in  the  plaster  bandage  are  Stilles'  shears.  (Fig. 
13.)  The  section  of  bandage  removed  falls  out  of 
the  window  of  the  cutting  blade.  These  shears 
are  constructed  like  some  of  the  bone  cutting  for- 
ceps, but  they  require  some  dexterity  in  passing 
about  an  angle  like  the  ankle  joint. 

After  the  plaster  is  divided  at  every  level,  the 
bandage  beneath  is  divided  with  shears.  Now  the 
whole  cast  may  be  lifted  from  the  limb,  much  in 
the  manner  that  a  hoop  is  sprung  from  a  barrel 


Fig.    13.      Stilles   shears. 

(Fig.  14),  or  by  a  motion  similar  to  the  opening 
of  calipers.  The  flannel  bandage  is  adherent  to 
the  plaster  and  comes  away  with  it  and  may  be  left 
thus  to  serve  the  purpose  of  a  lining.  If,  however, 
it  be  soiled  or  wrinkled  or  loose  it  should  be  re- 
moved. 

Eventually  the  cast  may  be  lined  with  absorbent 
cotton,  or  the  limb  invested  with  another  flannel 
bandage  or  tricot  before  replacing  the  cast.    Straps 


Replacement 
of  the  Cast 


20      I'L.ISTl-.R  01-  /'.IR!S  .IXP  HOW  TO  USE  IT 

of  adhesive  plaster  are  applied  circularly  over  the 
plaster  cast  (Fig.  15)  at  intervals  to  hold  it  in 
place  and  the  whole  recovered  with  a  moistened 
dextrine  or  starch  bandage  or  ordinary  muslin 
bandage. 


l''ig.    14.     Manner  of  removing  the  cast  from  tlic  limb. 


Fig.    15.     Iliuslraling   manner    of    reapplying   the    cast    with    adhesive 
straps. 


CHAPTER    II 

THE   APPLICATION    OF   THE   PLASTER   OF   PARIS    BAND- 
AGE  TO   INDIVIDUAL    FRACTURES 


There  is  hardly  a  fracture  of  any  bone  in  the 
body  requiring  immobilization,  for  which  the  use 
of  the  plaster  bandage  has  not  been  advocated.  En- 
thusiasts, indeed,  Avould  have  us  use  plaster  band- 
ages for  all  fractures.  An  enumeration  of  the  frac- 
tures for  which  the  plaster  bandage  is  neither  de- 
sirable nor  practical  will  best  show  its  limitations. 
These  are:  fractures  of  the  skull  (for  obvious 
reasons)  ;  of  the  clavicle;  of  the  ribs;  of  the  shaft 
of  the  femur  in  infancy,  in  all  cases,  and  in 
adolescence,  in  most  cases.  Extensive  compound 
fractures  afford  a  contraindication  to  the  use  of 
plaster  at  the  outset.  Its  use  being  deferred  until 
the  inflammatory  signs  have  subsided.  In  all  other 
fractures  the  use  of  a  plaster  of  Paris  cast  is  in 
place  at  some  time  or  other  during  the  treatment. 
In  fractures  of  the  forearm  and  arm  in  infants,  be- 
cause of  the  small  dimensions  of  the  parts,  plaster 
of  Paris  is  rather  to  be  preferred  to  splints.  The 
X-rays  readily  penetrate  the  plaster,  so  no  objection 
can  be  offered  to  its  use  on  this  score.  Yet  where 
great  detail  in  radiogram  is  sought  a  fenestra  may 
be  made  at  the  site  of  fracture  or  dislocation.  A 
window  in  front  and  at  the  back  of  the  cast  as 
recommended  by  Privat.  Except  when  applied  to 
the  lower  extremities,  its  weight  can  be  kept  down 
to  that  of  any  variety  of  splint. 

The  immediate  use  of  plaster  of  Paris  for  frac- 

21 


Fractures 
Suitable  for 
Plaster 


22    PLASTER  OF  PARIS  AND  IIOYV  TO  USE  IT 

tures  does  not  imply  its  instant  application. 
Usually,  several  hours  elapse  before  the  bandage 
General  is  applied ;  by  which  time  the  swelling-  about  the 
Considerations  fracture  will  have  attained  its  maximum.  If  it  is 
desired  to  reduce  this  swelling,  or  keep  it  at  its 
minimum,  elevation  of  the  limb,  massage,  the  use 
of  a  flannel  or  rubber  bandage,  preliminary  to  the 
application  of  the  plaster  bandage,  will  accom- 
plish this.  In  the  use  of  the  plaster  of  Paris  band- 
age, perhaps  more  so  than  with  other  sorts  of 
splints,  an  anesthetic  is  often  required,  and  for  the 
following  reason:  If  the  patient  be  at  all  restless 
while  the  deformity  is  being  corrected  and  align- 
ment maintained,  it  is  veiy  likely  that  the  plaster 
bandage  will  be  put  on  with  undue  pressure ;  and 
violent  motions  of  the  patient  may  crack  the 
quickly-setting  plaster.  If  swelling  of  the  fingers 
or  toes  or  of  the  extremities  distal  to  the  bandage 
should  supervene,  the  immediate  removal  of  the 
bandage  is  by  no  means  always  necessary.  Before 
taking  this  step  we  should  be  guided  by  the  color, 
warmth  of  the  toes  and  fingers  left  exposed  for 
this  very  purpose,  and  the  amount  of  pain.  If  the  ex- 
tremity be  cold^  blue,  anesthetic,  or  extremely  pain- 
fid,  and  a  pulse  cannot  he  felt,  there  should  be  no 
hesitancy  in  the  instant  loosening  of  the  cast  by 
splitting  it.  On  the  other  hand,  if,  in  spite  of  the 
swelling,  the  limb  be  warm,  and  not  unduly  red  (in- 
flammation excluded),  and  the  accompanying  pain 
and  throbbing  be  a  source  of  great  discomfort,  it  is 
desirable  to  resort  to  the  expedient  of  elevating  the 
entire  member  by  suspension  or  by  placing  it  upon 
cushions,  and  to  secure  absolute  rest  by  the  ad- 
ministration of  an  opiate.  If,  after  recourse  to 
these  measures  for  twenty-four  hours  at  the  ut- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    n 

most,  the  pain  persists  or  is  worse,  and  especially 
if  the  warmth  of  the  extremities  gives  place  to 
cold,  the  cast  must  be  split  forthwith.  Great 
caution  must  be  exercised  when  these  evidences  of 
circulatory  disturbances — swelling,  edema,  lividity 
— manifest  themselves ;  for  neglect  to  visit  the 
patient  frequently  may  cost  him  his  limb  and  the 
surgeon  his  reputation.  It  need  not  necessarily 
follow  that  the  limb  becomes  gangrenous — a  fate 
just  as  bad  awaits  a  limb  encased  in  plaster  of 
Paris,  when  the  patient  complains  of  paresthesia 
and  anesthesia.  The  undue  pressure  of  the  plaster 
of  Paris,  responsible  for  these  symptoms,  will,  if 
not  removed,  cause  ischemic  paralysis,  terminating 
in  permanent  contractures.  A  mere  splitting  of 
the  cast  in  its  entire  length  will  put  an  end  to  all 
the  untoward  symptoms  just  mentioned. 

Under  the  most  favorabje  circumstances,  in  the 
course  of  a  week  or  two,  with  the  subsidence  of  the 
swelling  the  cast  may  become  so  loose  that  it  is 
necessary  to  remove  it,  either  to  pad  its  interior 
with  non-absorbent  cotton,  or  to  make  a  thicker 
investment  of  the  limb;  after  either  of  which  pro- 
cedures the  cast  may  be  replaced.  An  undue 
amount  of  perspiration  with  severe  itching,  or  the 
presence  of  a  solid  substance  which  had  accident- 
ally made  its  way  beneath  the  plaster,  also  demands 
the  cutting  of.  a  window  for  the  removal  of  the 
foreign  body. 

When  applying  a  plaster  bandage  for  fracture, 
whether  to  the  upper  or  the  lower  extremity,  the 
body  ought  to  be  in  a  recumbent  position.  The' 
arm,  leg  or  thigh  to  be  bandaged  should  project 
beyond  the  edge  of  the  table  and  be  supported  by 
an  assistant.     It  is  impossible  to  apply  a  plaster 


Postur* 


Extent   of 
Bandage 


2A    PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 

bandage  to  the  extremities  of  an  infant  struggling 
in  the  arms  of  its  mother  or  nurse;  nor  is  the  sit- 
ting posture  in  an  adult  conducive  to  that  relaxa- 
tion of  the  muscles  necessary  for  the  proper  ap- 
plication of  the  bandage  to  the  extremities. 

It  may  be  stated  as  a  general  rule  that  the  plas- 
ter bandage  should  in  fractures  of  the  shaft  of 
long  bones  include  the  adjacent  articulations  and 
extend  well  beyond  the  joints.  Particularly  does 
this  obtain  with  the  lower  extremity. 


CHAPTER  III 

FRACTURES    OF   THE    UPPER   EXTREMITY 

The  patient  should  be  placed  on  his  back,  with 
the  body  close  to  the  edge  of  the  table,  and  both 
forearm  and  arm  extending  beyond  the  edge,  sup- 
ported by  an  assistant.      (Fig.   i6.)      The  deform- 


Fracture  of 
One  of  Both 
Bones  of 
Forearm 


Fig.    1 6.     Application    of    plaster    of    Paris    bandage    for    fracture    of 
the   forearm. 


ity  is  reduced  by  manipulating  the  fragments, 
making  hyperextension  and  flexion  in  the  antero- 
posterior or  lateral  direction,  associated  with  su- 
pination or  rotation.  The  proper  alignment  ac- 
complished (an  anesthetic  to  be  administered  if 
necessary),  the  assistant  grasps  the  patient's  hand, 
as   in   the   act   of    hand   shaking,    making   traction 

25 


26    PLASTER  OF  P.IRIS  AND  IIOW  TO  USE  IT 

and  executing  counter-extension  if  necessary,  or 
merely  supporting  the  forearm — whichever  is 
necessary  to  maintain  the  alignment.  The  plaster 
bandage  should  extend  from  the  icrist  to  the  flex- 
ure of  the  elboii'.  The  flannel  bandage  immedi- 
ately investing  the  forearm,  however,  should  ex- 
tend to  the  heads  of  the  metacarpal  bones,  thus  en- 
veloping the  hand.  The  fingers  are  left  free.  Thus 
we  prevent  edema  of  the  dorsum  of  the  hand,  and 
by  the  color  of  the  fingers  we  may  judge  of  the 
circulation.  If  the  fracture  of  the  radius  or  ulna, 
or  of  both  bones,  be  in  the  upper  third,  it  may  be 
necessary  to  flex  the  forearm  on  the  arm.  In  that 
event  the  plaster  of  Paris  bandage  will  include  the 
elbow,  and  must  be  carried  up  the  arm  as  far  as 
the  fold  of  the  pectoral  muscle,  to  secure  the  right 
purchase.  If  the  plaster  bandage  on  the  arm  ex- 
tends only  a  little  above  the  level  of  the  elbow  joint 
or  half  way  up  the  arm,  the  weight  of  the  plaster 
bandage  on  the  forearm,  by  breaking  up  the  flexion, 
will  cause  the  upper  part  of  the  bandage  to  press 
into  the  soft  parts.  The  flexure  of  the  elbow  should 
be  well  cleansed,  dried  and  dusted  freely  Avith  bis- 
muth subgallate  (dermatol),  before  the  bandaging, 
to  prevent  chafing    (dermatitis). 

In  fracture  of  the  shaft  of  the  humerus  in  its 
middle  or  lower  third,  when  we  are  not  concerned 
with  the  abduction  of  the  upper  fragment,  a  plaster 
of  Paris  dressing  is  suitable.  The  patient  occupies 
Fracture  of  a  sitting  posture.  The  reduction  having  been  ef- 
Shaft  of  fected,  under  anesthesia  if  necessar}^  the  limb  is 
brought  into  adduction,  so  that  the  chest  wall  forms 
an  internal  splint.  A  thin  layer  of  non-absorbent 
cotton,  well  dusted  on  both  sides  with  dermatol, 
being  interposed  between  the  arm  and  the  chest 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    27 

wall,  the  arm  is  held  against  the  thorax  by  cir- 
cular turns  of  a  muslin  bandage,  which  pass  ob- 
liquely over  the  shoulder,  enveloping  it.  The  fore- 
arm is  left  free,  so  that  by  its  weight,  even  though 
supported  by  a  sling  about  the  wrist,  it  exerts  ex- 
tension on  the  lower  fragment.  (Fig  17.)  In  the 
same  manner,  the  plaster  of  Paris  bandage  envelopes 
the  arm  and  shoulder,  securing  them  to  the  chest.  A 


Fig.    11 


Plaster    shoulder    spica    for    fracture    of    upper    humerus. 


layer  of  cotton  wool  should  be  placed  over  the 
clavicle  and  shoulder,  to  prevent  pressure  by  the 
plaster  bandage.  For  infants  but  one  bandage,  five 
yards  in  length,  is  necessary;  for  adults,  two  will 
suffice.  The  forearm  should  be  snugly  wound  with 
a  flannel  bandage,  to  prevent  the  development  of 
edema.     At   the    expiration   of   two    weeks,   when 


2S    PLASTER  OP  PARIS  AND  HOW  TO  USE  PP 


Fracture  of 

Joint 

the  Elbow 


the  plaster  bandage  is  removed  if  consolidation  is 
firm,  a  simple  tentative  dressing  may  be  applied. 

Ejcperience  has  taught  that  the  plaster  dressing 
is  not  well  suited  to  fracture  of  the  elbow  joint, 
other  dressings  being  better  adapted.  When,  how- 
ever, the  plaster  bandage  is  chosen,  the  following 
steps  in  its  application  should  be  observed.  The 
patient  occupies  a  recumbent  position,  and  the  arm, 
projecting  beyond   the   tdge.  of   the   table,   is   sup- 


rig.    iS.     Plaster    cast   for   lower   third    of   the    arm,    tlie    elbow,    or 
the    upper   third    of   the    forearm. 

ported  by  an  assistant.  (Fig.  i6.)  The  forearm  is 
flexed  as  acutely  as  possible.  In  the  flexure  of  the 
elbow  joint,  freely  dusted  with  dermatol,  a  thin  layer 
of  cotton  batting  is  placed,  and  the  bony  prominences 
are  also  enveloped  in  non-absorbent  cotton.  The 
arm  and  forearm,  from  the  axillary  fold  to  the 
wrist,  are  invested  with  a  flannel  bandage,  and  over 


PLASTER  OF  PARIS  AND  PIOIV  TO  USE  IT    29 


this,  in  turn,  a  plaster  of  Paris  bandage  is  placed. 
(Fig.  18.)  The  plaster  bandage  does  not  cover 
the  upper  and  lower  limits  of  the  flannel  bandage. 
These  are  turned  back  so  as  to  form  a  cuff  at 
either  end,  a  single  turn  of  the  plaster  bandage 
being  sufficient  to  secure  them.  This  cuff  prevents 
the  edge  of  the  plaster  from  pressing  into  the  skin, 
and  guards  against  unraveling  of  the  flannel  band- 
age. 

Allis  believes  that  the  essential  thing  in  the 
treatment  of  fractures  of  the  elbow  is  to  main- 
tain the  normal  carrying  angle  at  the  elbow.  This 
implies  an  abduction  of  the  forearm.  This  degree 
of  abduction  is  apparent  only  with  the  forearm 
in  extension  and  mid  supination.  Such  angle 
should  be  restored  when  it  is  eft'aced  in  elbow 
fractures  and  a  plaster  oast  applied  with  the  elbow 
extended  from  the  upper  end  of  the  humerus  to 
the  wrist.  After  two  weeks  this  cast  is  removed 
and  active  and  passive  motions  begun. 

In  all  respects  the  plaster  bandage  is  to  be  ap-  CoUes'  Fractur 
plied  here  like  the  cast  described  for  fracture  of 
one  or  both  bones  of  the  forearm,  save  that  the 
wrist  is  included,  and  the  bandage  is  carried  down 
to  the  heads  of  the  metacarpal  bones.  (Fig.  19.) 
Other  varieties  of  plaster  dressings  used  for  Colles' 
fracture  are  described  further  on  under  the  heading 
Braatz  spiral  molded  splint  and  a  posterior  molded 
splint. 

Caution:  It  is  this  immobilization  of  the  wrist, 
however,  which  constitutes  a  great  drawback  to  the 
use  of  plaster  of  Paris  in  this  fracture,  for  which 
many  other  devices  are  far  better  suited. 

This  is  the  one  finger  for  which,  if  it  is  frac-    Fracture  of 
tured  in  any  of  its  parts,  a  plaster  of  Paris  dressing    the  Thumb 


30    PLASTER  OF  PARIS  AND  IIOIV  TO  USE  IT 


is  suitable.  Wlicther  the  first  or  second  phalanx  or 
the  metacarpal  bone,  is  fractured,  the  thumb,  in  the 
extended  and  abducted  position,  is  covered  with  a 
flannel  bandage  spica,  passing  in  figure-of-eight 
turns  about  the  wrist,  or  a  cotton  glove,  with  the 
other  fingers  cut  off,  is  slipped  over  the  hand. 
Either  investment  is  covered  with  a  "spica  pollicis" 
of  plaster  of  Paris,  including  the  wrist  and  termi- 


Cast    for    fracture    of    forearm    or    wrist. 


Fracture  of 

le  Metacarpal 

and  Carpal 

Bones 


nating  an  inch  above  it.  (Figs.  20,  21.)  The  plaster 
bandage  below  reaches  to  the  heads  of  the  meta- 
carpal bones.  As  in  all  other  casts,  the  edge  of 
the  plaster  bandage  is  covered  with  the  last  turn 
of  the  flannel  bandage. 

If  the  fracture  be  in  the  shaft,  or  near  the  base 
of  the  metacarpal  bones,  or  in  a  carpal  bone,  the 
hand,  exclusive  of  the  fingers  but  inclusive  of  the 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    31 


wrist  and  two  inches  of  the  forearm,  is  invested 
with  a  flannel  bandage,  and  this  in  turn,  is  cov- 
ered with  a  plaster  of  Paris  bandage  two  inches 
in  width.  (Fig.  17.)  For  fractures  of  the  heads 
of  the  metacarpal  bones  or  phalanges,  dressings 
other  than  plaster  of  Paris  are  commendable. 
While  no  general  rule  can  be  formulated  as  to 


Fig. 


THUMB    SPICA 
20.     Dorsal    view.  Fig. 


21.     Palmer    view. 


when  the  cast  should  be  wholly  set  aside  in  each 
of  the  fractures  considered,  it  should  be  the  prac- 
tice at  the  end  of  the  second  week  to  remove  the 
cast  and  inspect  the  site  of  fracture.  This  is  done 
to  ascertain,  not  so  much  the  extent  of  union  as 
judged  by  the  wanton  practice  of  undue  manipula- 
tion to  elicit  mobility,  but  rather  to  note  whether 


Time  Limit  for 
Removal  of 
Plaster  Casts 
in  Fractures  of 
Upper 
Extremity 


32    PLASTER  OF  PARIS  .IXD  HOW  TO  USE  FT 

there  is  any  marked  dcfonnity,  /.  c,  if  liie  align- 
ment is  the  best  possible.  I'or  neither  a  plaster 
of  Paris  cast  nor  any  other  splint  is  designed  to 
correct  any  deformity,  but  only  to  hold  the  cor- 
rectly placed  fragments  in  situ. 

When  the  X-rays  are  available,  and  by  their 
use  it  is  clearly  seen,  perhaps  on  the  fluoroscopic 
screen,  but  preferably  in  radiograms,  that  the  ap- 
position of  the  fragments  is  all  that  could  be  de- 
sired, we  may  forego  the  removal  of  the  cast  for 
the  purpose  of  inspection.  To  obtain  a  good  radio- 
gram it  may  be  desirable  to  fenestrate  the  plaster 
bandage  in  front  and  back  of  the  site  of  fracture, 
eventually  filling  in  the  window  with  cotton  fol- 
lowed by  turns  of   crinolin  or  plaster  bandage. 

If,  however,  on  removal  of  the  cast  the  align- 
ment is  apparently  straight — to  the  naked  eye  as 
well  as  the  sense  of  touch,  and  though  the  X-ray 
findings  are  contradictory  to  a  degree — such  mal- 
position w^ill  not  be  incompatible  wi-th  eventual 
good  function."  The  cast  may  be  replaced  or  re- 
newed to  await  the  time  of  complete  union. 


CHAPTER  IV 


FRACTURES    OF    THE    LOWER    EXTREMITIES 


Every  cast  applied  for  fracture  of  the  hip,  thigh. 
knee,  or  leg  should  include  the  foot  in  a  right-an- 
gled position.  Failure  to  do  this  will  cause  drop- 
foot  (talipes  equinus),  which  constitutes  a  hin-  General  Rule 
drance  to  walking  during  the  time  that  the  cast 
is  in  place,  and  delays  walking  after  its  removal.  In 
neglected  instances,  indeed,  this  drop-foot  requires 
correction,  eventually,  and  the  application  of  a  plas- 
ter cast  in  turn  to  restore  the  position  to  a  right 
angle. 

The  use  of  a  plaster  cast  in  fractures  of  the  se- 
nile hip  is  indicated  only  if  it  is  possible  to  have 
the  patient  walk  about  on  crutches.  Other  device*^ 
are  more  effective,  but  at  times  not  applicable,  be- 
cause they  necessitate  the  patient  assuming  a  re- 
cumbent position  for  many  weeks,  which  is  apt  to 
cause  hypostatic  congestion  of  the  lungs.  The  most 
effective  plaster  dressing  is  that  which  includes  the 
knee  and  ankle,  enveloping  the  hip  in  a  spica,  the 
upper  limits  of  which  include  the  ribs  below  the 
mammary  level.  After  one  week  or  ten  days  in 
a  recumbent  position  such  patients  may  be  encour- 
aged to  walk  on  crutches,  swinging  the  broken  hip. 
It  rarely  comes  to  pass  in  the  fracture  of  the  hip 
of  the  aged,  to  apply  such  a  plaster  dressing.  In 
juvenile  cases  it  is  practical. 

The  patient  occupies  the  recumbent  posture,  on  a         piaster  of 
kitchen  table  or  a  board  resting  on  two  horses.   The        Paris 
pelvis  must  be  well  down  to  the  edge  of  the  table,         Hip  Spica 
the  sound  limb  hanging  over  the  edge  and  resting 

33 


Fracture  at  th« 
Hip  Joint 


34    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

with  its  foot  on  some  support.  The  affected  limb 
is  held  by  an  assistant,  who  exerts  extension,  at  the 
same  time  abducting  the  thigh.  To  prevent  the  dis- 
placement of  the  body  by  the  traction  eft'orts,  the 
lower  entl  of  the  table  may  be  slightly  raised.  (Fig. 
22.)  In  addition,  if  much  traction  is  called  for,  a 
sling  made  of  a  twisted  bed  sheet,  is  passed  beneath 
the  crutch  (perineum)  and  its  ends  secured  to  one 
of  the  further  legs  of  the  table,  or  held  by  another 
assistant  stationed  at  the  head,  to  exert  counter  ex- 
tension. The  more  perfect  the  reduction  the  less 
need  for  traction  extension  and  the  likelihood  of  dis- 


Fig.    22.     Posture    in   applying   cast    for    hip    fracture. 

placing  the  patient.  For  that  part  of  the  dressing 
which  invests  the  lower  part  of  the  thigh,  the  knee, 
leg  and  ankle,  the  pelvis  may  rest  flat  on  the  table, 
but  while  the  turns  of  the  hip  spica  are  applied,  the 
pelvis  must  be  elevated.  This  elevation  can  be  ac- 
complished in  a  variety  of  ways — by  an  apparatu'^. 
such  as  a  hip-rest  or  by  improvised  devices.  Of  the 
former,  the  one  here  illustrated,  made  of  a  band 
of  iron  or  steel  bent  as  shown  (Fig.  23),  and 
screwed  to  a  plank,  is  pushed  under  the  sacrum. 
Other   hip    rests   as    pictured    in    diagram    may   be 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    35 

clamped  to  table.  It  is  also  necessary  to  have  a 
support  under  the  shoulders  so  as  to  bring  them 
on  a  level  with  the  pelvis.  The  blade  supporting  the 
pelvis  is  covered  in  by  the  turns  of  the  plaster  band- 
ages, but  it  can  be  easily  withdrawn  after  the  plas- 
ter has  set.  Where  no  hip  rest  is  at  hand  a  sling  of 
stout  muslin  playing  about  a  pulley  secured  over- 
head, may  be  used  to  raise  the  pelvis,  the  loop  of 
the  sling  becoming  incorporated  in  the  bandage.  In 
other  instances  the  pelvis  must  be  supported  on  an 
improvised  hip  rest — by  hands,  or  on  the  superim- 
posed fists  of  an  assistant  (Fig.  24),  or  an  agate 
ware  basin  reversed.     These  preliminaries  effected, 


Fig.   23.     Metal  hip  rest,  screwed  to  board. 

the  bony  prominences  of  the  spines  and  crest  of  each 
ilium  are  covered  with  cotton  batting  or  pads  of 
piano  felt.  A  flannel  bandage  now  invests  the  foot, 
leg,  thigh,  hip,  waist.  Over  this  the  plaster  of 
Paris  bandage  is  applied. 

A  narrow  strip  of  piano  felt  or  a  belt  made  of 
non-absorbent  cotton  (batting)  is  desirable  about 
the  waist  to  fill  out  the  hollow,  for  in  this  situation 
the  spica  is  very  likely  to  crack.  This  accident 
may  still  further  be  guarded  against  by  increasing 
the  turns  of  the  bandage  at  that  level  and  rein- 
forcing the  bandage  at  the  thigh  flexure  by  super- 
imposing several  layers  of  the  bandage  made  to  pass 


36    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

to  and  fro.  The  perineum  must  be  particularly 
guarded  by  proper  padding,  and  if  the  turns  of  the 
bandage  hug  it  too  closely  a  crescentic  segment  must 
eventually  be  removed  to  avoid  the  production  of 
a  pressure  sore.  This  part,  also,  must  be  well  dusted 
with  dermatol  or  talcum,  and  either  one  of  these 
powders  is  to  be  blown  in  under  the  upper  margin 
and  about  the  pubis,  to  prevent  irritation  of  the 
skin.  The  bandage  should  be  well  molded  about 
the  iliac  bones  and  eventuallv  trimmed  as  shown  in 


.14.      Superimposed    fists    for    hip    rest. 


Fracture  of 

the  Femur 

(Shaft) 


(Figs.  25.  26.)  That  part  of  the  cast  in  the  vicinity 
of  the  genitals  may  be  coated  with  shellac  so  that 
urine  or  vaginal  secretions  does  not  penetrate  the 
cast,  rendering  it  foul  and  brittle. 

The  position  occupied  by  the  patient  in  applying 
this  bandage  is  the  same  as  described  for  fractures 
at  the  hip.  The  cast  should  extend  from  the  waist 
(umbilicus),  and  should  include  the  foot  at  right 
angles. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    27 

In  children,  fracture  of  the  neck  of  the  femur  is 
associated  with  adduction  of  the  thigh.  Where  this 
diagnosis  obtains,  the  extremity  should  be  put  up 
in  a  position  of  marked  abduction.  In  walking 
about  with  the  aid  of  crutches  a  patten  is  to  be 
worn  on  the  healthy  foot  or  the  sole  and  heel  raised 
so  that  the  limb  encased  in  plaster  clears  the  floor. 
(See  Fig.  82.) 


Fig.    25. 


Fig.    26. 


Anterior    and    posterior    view — extent    of    cast    for    fracture    of    hip 
and   femur. 

In  children,  a  plaster  of  Paris  spica  may  also  be 
applied  by  suspending  the  patient  in  a  Sayre's  sus- 
pension apparatus.      (Fig.  27.) 

Fractures  involving  the  Knee  Joint  and  Frac- 
tures IN  THE  Upper  Half  of  the  Leg  require  a 


Fractures 
Knee  Joint 
and  Upper 
Half  of 
Leg 


3S    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

bandage  to  be  apj)lie(l  extending  from  Pouparts 
and  investing  the  foot  in  a  right  angle  position. 
Attention  should  be  directed  to  mold  the  bandage 
about  the  knee.  (Fig.  28.)  To  prevent  this  cast 
from  sliding  down  a  suspender  may  be  carried  over 
the  shoulder  and  secured  to  holes  in  the  cast  or  it 
may    he    suspended    from    a  belt  about  the  waist. 


Fig.    27.     Application    of    plaster    hip    spica    in    suspension. 


actures  of  the 

-ower  Half  of 

B  Tibia  and  at 

the  Ankle 

Joint 


These  fractures  are  usually  so  severe  and  are 
accompanied  with  such  deformity  that  they  necessi- 
tate a  narcosis  to  make  the  proper  correction.  Fur- 
thermore, if  unattended  by  a  wound  they  are  the 
fractures  of  the  lower  extremity  best  suited  for  the 
ambulatory  cast. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    39 

The  patient  occupies  the  supine  position.  Tlie 
flannel  bandage  or  tricot  hose  (Fig.  29)  extends 
from  the  condyles  of  the  tibia,  and  the  lower  mar- 
gin of  the  patella,  and  includes  the  foot — which  is 
held  at  right  angles  by  an  assistant,  as  follows :  The 
heel  is  supported  on  the  left  hand  in  the  grasp  of 


1^! 
i      \ 


Fig.  28.     Plaster  cast  for  fracture  of  upper  half  of  'leg.      Note  right- 
angled   position   of   foot,   and   extent   of   cast. 


the  index  finger  and  thumb,  whereas  with  the  right 
hand  pressure  is  exerted  upwards  on  the  foot  by  the 
right  thumb  pressing  on  the  ball  of  the  toe,  thereby 
forcing  the  foot  into  a  right  angled  position.  If 
now  the  knee  he  Hexed  and  the  limb  steadied  by 


Fig.    29.     Illustrating   tricot  hose   investment   in    fracture   of   the   leg. 

another  assistant  grasping  the  calf,  the  muscles  of 
the  calf  will  be  relaxed  and  the  right  angle  of  the 
foot  easier  maintained.  (Fig.  30.)  The  crest  of  the 
tibia  is  covered  with  non-absorbent  cotton  to  pro- 
tect it  from  pressure.  When  there  is  no  assistant 
to  hold  the  foot,  a  muslin  bandage  sling  is  passed 


40    PLASTER  OF  I'.IRIS  ,1X1)  HOW  TO  USE  IT 

about  the  great  toe  (l"ig.  31)  and  either  heUl  taut 
b}'  the  patient,  if  he  be  conscious,  so  as  to  bring  the 
foot  at  right  angles  to  the  leg,  or  the  strings  of  the 
bandage  are  fastened  to  the  upper  end  of  the  table. 
About  the  condyles  the  plaster  of  Paris  bandage 
is  to  be  heavily  applied  so  as  to  form  a  cuff. 

The  cast  which  is  most  desirable  for  fractures  at 
tJic  ankle  joint  differs  from  the  preceding  only  in 
the  very  important  particular,  the  position  of  the 
foot. 


Fig.    30.     Manner    in    which    assistant   holds    foot    for    application    of 
plaster  bandage. 


This  variety  of  fracture  is  most  commonly  fol- 
lowed by  flat-foot.  To  obviate  this  it  will  always  be 
necessary  to  have  the  foot  zocll  inverted  (varus) 
and  at  a  right  angle  to  the  shaft  of  the  tibia.  The 
crux  i)i  a  properly  applied  bandage  of  the  ankle 
joint  is  to  have  the  foot  at  a  right  angle.  (Fig.  32.) 
Thus  the  patient  is  made  to  walk  on  the  outer  side  of 
his  foot.  When  it  is  intended  that  the  cast  should 
be    an    ambulatory   one,    a    cuff   of   plaster    should 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    41 

closely  hug  the  head  of  the  tibia  and  an  extra  num- 
ber of  turns  of  plaster  of  Paris  should  be  passed 
about  the  lower  fourth  of  the  leg,  some  of  them  em- 
bracing the  ankle.  To  protect  the  tendo-achilles  from 
pressure  a  pad  of  non-absorbent  cotton  should  be 
placed  to  either  side  of  it. 

The  upper  limit  of  this  plaster  cast,  while  it  must 
closely  embrace  the  condyles,  should  not  encroach 
upon  the  popliteal  space  where  it  would  limit  flexion 
at  the  knee  joint.    This  is  avoidable  by  cutting  out  a 


Fig.   31.     Foot  being  drawn  up  at  right  angle  by  a   strip   of  bandage 
held  by  patient. 

crescentic  strip  of  plaster  with  the  penknife  while 
the  bandage  is  yet  in  the  plastic  state.  Other 
points  of  pressure  in  this  cast  are  generally  encoun- 
tered on  the  inner  and  outer  aspects  of  the  foot. 
These  are  avoided  by  not  carrying  the  turns  of  the 
plaster  bandage  so  far  forward  as  to  impinge  on 
the  toes.  If  these  pressure  points  do  give  trouble, 
greater  relief  will  he  afforded  by  splitting  the  ban- 
dage on  either  its  inner  or  its  outer  side,  than  by 


42    PLASTER  OF  PARIS  AMD  HOW  TO  USE  IT 

cutting  off  any  bandage  in  the  circular  direction 
(Fig.  23-)  Beneath  the  plaster  adhesive  straps  may 
be  applied  to  the  limb  to  carry  out  extension.  Those 
who  believe  in  early  massage  of  fractures  divide  this 
cast  in  two  parts  (bivalve)  so  as  to  permit  of  its 
daily  removal  and  reapplication  after  massage. 
A  fracture  of  the  bones  of  the  foot  may  be  very 


Fractures  of 
the  Foot 


rig.    32.     Ambulatory   cast    for   fracture   of  le?. 

well  treated  by  a  plaster  of  Paris  bandage,  including 
the  ankle  and  terminating  over  the  lower  third  of 
the  leg,  below  the  level  of  the  calf  (Fig.). 

Caution:  The  dorsum  of  the  foot  should  be  well 
protected  from  pressure  by  a  padding  of  non- 
absorbent  cotton.  When  the  metatarsal  bones  are 
fractured,  a  pad  of  piano  felt  should  be  placed  on 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    43 

the  plantar  surface  as   an   effort  to  preserve   the 

transverse  arch,  and  Hkewise  a  padding  to  either 

side  of  the  tendo  achilles  to  protect  it  from  pressure. 

This  term  appHes  to  an  ordinary  plaster  of  Paris  Fenestrated 

bandag-e  in  a  part  of  which  a  window  is  cut  to  per-  piaster  of 

mit  of  treating  the  underlying  wound.      (Fig.  34.)  Paris  Dressing 

The  opening  in  the  cast  should   always  be  larger  f°r  Compound 
,1         ^1  1  Fractures 

than  the  wound. 

The  window  can  be  made  in  a  variety  of  ways. 
A.     The  wound,  covered  with  appropriate  dress- 
ing, may  be  included  in  the  plaster  of  Paris  dress- 


Fig.  33.     Demonstrating  method  of  splitting  cast  to  obviate  pressure. 

Methods  of 

ing.     Its  location  having  been  noted  by  measure-  Fenestration 

ment,  a  window  corresponding  to  its  dimensions  is 
then  cut  with  a  penknife  from  the  plaster  before  it 
has  set.  The  flannel  or  tricot  investment  is  not  cut 
away;  it  is  conically  split  and  these  flaps  are  then 
turned  over  the  rough  edges  of  the  plaster.  The 
rough  edges  of  the  plaster  bandage  can  be  smoothed 
and  still  further  protected  from  the  discharge  of 
the  wound  by  investing  the  edges  with  adhesive 
plaster,  or  with  gutta  percha  tissue  made  to  adhere 
with  chloroform,  or  by  an  application  of  shellac. 


4/1    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

B.  The  wound,  duly  protected,  is  covered  with  a 
measuring  glass,  a  graduate  or  a  tumbler  of  con- 
venient size,  the  turns  of  the  plaster  of  Paris  bandage 
passing  about  the  glass. 

C.  A  piece  of  cardboard,  blotting  paper  or  felt 
corresponding  to  the  size  of  the  wound  is  pene- 
trated at  its  center  by  a  pin.  This  device  is  placed 
over  the  wound  and  the  l)andage  applied  in  the  usual 
fashion.  The  pin  appears  through  the  bandage  and 
affords  a  guide  where  to  make  the  window.  If  a 
duplicate  of  the  blotting  paper  be  slipped  over  the 
pin  the  exactness  of  the  window  location  will  be 
assured  still  more.    This  last  is  the  best  method. 

Ambulatory         -pj-^^  treatment  of  fractures  of  the  leg  and  particu- 


Fig.    34.     Showing   plaster   of   Paris   siilint   with    two   fenestra:. 

larly  those  of  the  ankle,  w'liere  there  is  no  axial  dis- 
placement of  the  fragments,  demanding  extension, 
are  best  suited  for  the  "ambulatory  cast." 

It  is  the  practice  of  some  surgeons  to  have  the 
upper  limits  of  the  cast  at  the  condyles  of  the  tibia, 
others  would  include  the  knee  joint,  extending  to 
the  gluteal  folds  posteriorly  and  to  Pouparts  in 
front. 

The  indications  for  the  choice  of  either  may  be 
set  down  as  follows:  Where  the  fracture  is  limited 
to  the  ankle  joint  a  cast  extending  to,  and  embracing 
the  condyles,  is  sufficient.  All  fractures  above  the 
m.iddle  of  the  leg  call  for  immobilization  of  the  knee 
also.    Under  these  circumstances  the  cast  should  be 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    45 

carried  up  to  the  gluteal  fold  posteriorly  and  Poit- 
parts  ligament  anteriorly. 

Experience  has  shown  that  no  metal  or  wood 
strips  need  be  incorporated  in  the  plaster  of  Paris 
dressing.  The  ambulatory  plaster  of  Paris  splint 
differs  from  the  ordinary  plaster  dressing  applied  for 
a  like  fracture,  in  the  extent  of  the  immobilization, 
in  the  greater  number  of  the  plaster  of  Paris  ban- 
dages used,  and  in  the  increase  in  thickness  of  the 
plaster  of  Paris  bandage  by  multiplying  the  turns 
at  certain  levels.  The  one  situation  favored  by  in- 
crease in  thickness  to  prevent  cracking,  is  just  above 
the  ankle  joint.  The  upper  limit  of  the  plaster  about 
the  condyles  of  the  tibia  is  also  increased  in  thick- 
ness so  that  the  weight  of  the  body  transmitted  to 
the  cast  will  not,  in  being  transferred  to  the  knee 
and  thigh,  cause  the  cast  to  cut  into  the  soft  parts, 
as  would  be  the  case  with  a  thin  edge  of  plaster-. 
The  ambulatory  plaster  splint  is  practicable  in  a 
fracture  of  the  ankle  or  leg  without  a  stirrup,  by 
virtue  of  the  mechanical  fact  that  in  a  pillar,  the 
stress  and  strain  are  distributed  on  the  surface. 
Hence  the  column  of  plaster  about  the  fractured 
leg  carries,  in  greater  part,  the  superimposed  weight 
of  the  body.  To  give  some  elasticity  to  the  rigid 
plaster  beneath  the  plantar  surface  of  the  foot,  some 
authorities  advocate  the  insertion  of  a  layer  of  felt. 
A  stirrup  may  be  employed  in  fractures  of  the  ankle 
joint.  In  this  event  the  vertical  branches  of  the 
stirrup  should  be  invested  with  rubber  tissue  to  pre- 
vent rusting  and  covered  with  non-absorbent  cotton, 
it  should  be  placed  between  the  layers  of  plaster 
bandage.  The  Thomas  knee  splint  used  in  conjunc- 
tion with  such  a  cast  is  a  very  effective  way  in  am- 


46    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

bulatory  treatment  of  leg  fractures.  A  patten  is  to 
be  worn  on  the  sound  limb. 

Exceptionally,  fractures  of  thigh,  more  frequently 
those  at  the  hip  joint  when  encased  in  a  plaster  of 
Paris  dressing  in  an  abducted  position,  are  treated 
ambulatory.  There,  too,  some  form  of  hip  splint 
should  be  used  in  conjunction  as  a  means  of  pro- 
tection. 

The  use  of  the  ambulatory  plaster  of  Paris  splint 

.     ,    ,        ^   does  not  imply  that  walkinsf  with  a  fractured  limb 
Ambulatory        .„   ,  . ,  •;  Air  11 

Plaster  of   '^^'      "^  possible  at  once.     Only  after  several  days, 

Paris  Cast  niost  commonly  at  the  end  of  the  first  week,  the 
patient  can  make  efforts  at  standing  and  gradually, 
as  he  gains  confidence,  the  limb  can  be  used  to  walk 
with.  In  the  course  of  time  the  plaster  of  Paris  on 
the  sole  of  the  foot  softens.  This  may  be  unheeded, 
for  with  the  free  use  of  the  limb  the  foot  is  pro- 
tected with  either  a  felt  slipper  or  an  arctic. 
Fracture  of  j^  ygj-y  exceptional  instances,  where  there  is  so 
^  ^  ^  scant  a  separation  of  the  fragments  that  they  can 
be  approximated,  as  estimated  by  crepitus  or  the  use 
of  X-rays,  the  plaster  cast  surpasses  all  other  forms 
of  treatment,  and  in  such  instances,  where  opera- 
tion is  contraindicated,  the  use  of  plaster  of  Paris 
is  pre-eminently  indicated. 

The  chief  point  to  be  considered  in  its  application, 
is  that  the  turns  of  the  bandage  must  fit  snuglv 
about  the  upper  and  lower  limits  of  the  patella.  This 
can  be  accomplished  best  by  molding  the  bandage 
down  upon  the  patella  while  it  is  in  the  plastic  state. 
Previous  to  applying  the  cast,  approximation  may 
be  facilitated  by  passing  adhesive  straps  obliquely 
about  the  upper  and  lower  limits  of  the  patella. 
Subsequent  to  the  application  of  the  plaster  of  Paris 
dressing,  a  radiograph  may  be  taken,  to  ascertain 
the  relation  of  the  fragments.     Inasmuch  as  it  is 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    47 

to  be  the  purpose  to  have  the  patient  to  walk  about, 
the  plaster  of  Paris  cast  should  include  the  foot  in 
a  right  angled  position,  and  extend  up  to  Pouparts 
ligament. 

If  the  plaster  cast  be  effective  in  maintaining  the 
fragments,  it  may  be  removed  after  the  lapse  of  two 
weeks,  to  permit  of  daily  massage,  and  replaced  each 
time. 

This  is  referred  to  here  for  the  application   of 


Fracture  of 
the  Olecranon 
Process 


Fig-    35-     \'eneering    strips    placed    the    length    of    the    arm. 


plaster  of  Paris  for  this  fracture  corresponds  in  all 

essentials  with  its  application   for   fracture  of  the 

patella,  just  described. 

Whenever    additional    material    is    incorporated 

among  the  layers  of  a  plaster  of  Paris  bandage,  it 

is  termed  a  "compound  plaster  of  Paris  bandage."   di°T°"^^t3    • 
•-pi  .      •   -i  •  ,  .  iriaster  01  Paris 

Ihese  materials  are  mcorporated  to  give  additional   Splints 

strength  to  the  bandage  and  incidentally  to  reduce 

its  weight. 

Strips  of  veneering  (Figs.  35-37)   tin  and  iron, 


48    PLASTER  OF  I'.IRIS  .1X1)  UOW  TO  USE  IT 

wire   netting   and    gutta   perclia   are   tlie   materials 
most   commonly   employed.     The   metals   are   least 


Fig.    36.     Use    of    veneering    strips    to    strcngtlien    the    cast. 

desirable  as  they   are  likely   to  become   rusty,   and 
bv  this  corrosion,  break  and  penetrate  the  bandage 


'■"'g-    37-     \'enecring    strips    spirally    wouml    about    tlie    cast. 


if  it  be  worn  a  long-  time,  and  splints  with  metal 
incorporated  are  difficult  to  remove. 

In  dressing  af- 
ter   resections    of 


the  elbow  and 
'  knee,  these  com- 
pound  plaster    of 

Fig.   38.     r.ridging  strips   of   metal    per-     PSHS    SplmtS    find 
mitting    motion^  and^^inspeetion    of  ^j^^j^.  greatest  USC- 

fulness. 


Segmented 
Splints 


When  it  is  desirable  to  have  access  to  the  wounds 

of  joints  (or  to 
wounds  extend- 
ing over  a  large 
part  of  the  cir- 
cumference    o  f 

_.    ^„     ,,..  ,,-..,    ^  an     extremity). 

Fie.  39.      \\  nc  worked  into  the  two  sec-  -'  ■' 

lions   of   the   plaster  cast   to   facilitate  ^  q    that    thcv 

suspension   of  the  limb.  "  ^ 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    49 


may  be  approached  from  all  sides,  the  joint  (or  other 
surface)  is  bridged  over  with  bands  of  metal,  or 
with  wire,  which  are  incorporated  in  the  turns  of  the 
segments  of  plaster  above  and  below  the  joint,  as 
shown  in  Figs.  38  and  39.  A  sufficient  curvature 
is  given  to  the  strips  so  as  to  permit  the  joint  to  have 
some  range  of  motion  eventually,  and  also  to  permit 
of  any  dressings. 

A  strand  of  wire  with  hooks  may  be  incorporated 

in  any  variety  of 
plaster    splint. 
These    hooks    fa- 
cilitate    the     sus- 
pension     of      the  Suspended 
limb,    as    may   be  Splints 
necessary    in    in- 
flammatory condi- 
tions.     (Fig.  40.) 
A    fenestrated    splint   may    also    have    wire    and 
booklets  incorporated  in  it  to  permit  of  its  suspen- 
sion.     (Fig.  41.) 


40.        (a)    Molded     splint     with     wire 
hooks    for    suspension;     (b)    the   . 
wire    itself. 


Fig.    41.      Suspended    fenestrated    plaster    cast. 


50    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

Heated     p  in  s       j^  certain  inflammatory  conditions  of  the  joints, 

(Perthes)  ...  ,,-',...         ,  ,.  .        ■*  ' 

notably  m  gonorrheal  arthritis,  in  addition  to  the 

immobilization  effected  by  plaster  of  Paris,  it  may 

be  desirable  to  supply  heat  to  the  parts.    When  this 

is  desired,  there  may  be  wound  about  the  cast  coils 

of  rubber  tubing,  or  narrow  tubing  of  lead  or  of 

flexible  tin.     Through  this  tubing  very  hot  water 

is  allowed  to  pass,  and  is  carried  off  into  a  pail. 


CHAPTER  V 


MOLDED  PLASTER  OF  PARIS  SPLINTS 


This  variety  of  splint  has  thus  far  been  but  cas- 
ually referred  to  in  the  previous  pages.  It  may  be 
made  in  a  number  of  ways. 


(a)    Correct. 


(b)    Incorrect. 
Fig.    42.      (a)     Spiral    folding;     (b)    concentric    folding. 

(A)  Pieces  of  crinolin  gauze  of  several  thick- 
nesses, folded  as  pictured  in  Fig.  42,  spiral,  not  con- 
centric, or  a  single  layer  of  flannel,  are  first  cut  to  the 
shape  of  the  parts  (antero-posterior  or  lateral  as- 
pects). They  are  then  steeped  and  kneaded  in  a 
plaster  of  Paris  paste  contained  in  a  receptacle.  The 
member  to  be  invested  is  thoroughly  anointed  with 
a  thin  layer  of  vaselin,  and  covered  on  both  sides 

51 


Molded  Splint 


5^    PLASTER  or  PARIS  AXD  HOW  TO  USE  FT 

with  the  fabric  impregnated  with  the  plaster  of 
Paris.  (Fig.  43.)  The  latter  is  held  in  place  by 
several  turns  of  muslin  bandage,  until  it  hardens. 


Fig.    43.     Molded    splint    ai'plicd. 

(Fig.  44.)      As  soon  as  the  setting  is  completed,  the 
turns  of  the  muslin  bandage  are  divided,  and  the 


Fig.    44.      Secured    by    bandage    while    hardening. 

splints  are  set  aside,  to  dry  still  further,  if  possible. 
They   are   then   lined    with   non-absorbent   cotton. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    53 

(Fig.  45.)  When  applied,  the  splints  are  to  be  held 
securely  in  place  by  circular  turns  of  adhesive  plas- 
ter, one  near  each  extremity  of  the  splint  and  the 
other  fastened  in  the  center.  (Fig.  46)  The  two 
splints  are  then  covered  with  a  gauze  or  muslin  ban- 
dage (Fig.  47),  and  this,  in  turn,  is  covered  with  a 
crinolin  bandage,  which  prevents  shifting  of  the 
splints. 


Fig.    45.      Splint    lined    with    cotton. 

The  advantages  of  this  variety  of  splint  over  the 
circular  plaster  of  Paris  bandage,  consist  in  its  light- 
ness of  weight,  and  the  ease  with  which  it  can  ba 
taken  off  and  put  back  again,  so  as  to  enable  inspec- 
tion and  to  better  the  reduction  of  the  fragments,  if 
necessary. 

(B)  Instead  of  impregnating  the  layers  of  gauze 
by  steeping  and  kneading  them  in  the  cream  of  plas- 


5^    PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 


]  ii".    46.     'J"wo    lialves    of    molded    splint    lu'ld    together    by    adhesive 
jilasler. 


Fig.   47.     Splint  covered  with   muslin  bandage. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    55 


ter,  the  latter  may  he  poured  on  the  gauze  from  a 
pitcher,  and  rubbed  into  the  meshes  with  the  hand. 
The  impregnated  gauze  is  then  appHed  as  in  the  pre- 
vious method.    This  is  a  rather  messy  procedure. 

(C)  A  third  manner  of  preparing  molded  splints 
is  directly  from  a  plaster  of  Paris  roller  bandage. 
A  bandage  of  the  desired  width  having  been  se- 
lected, it  is  cut  in  the  necessary  lengths,  ascertained 
by  measurement  on  the  limb.  To  prevent  the  crino- 
lin  from  curling  up,  a  w^eight  is  placed  upon  either 
end.  Warm  water  is  then  allowed  to  drip  on  the 
several  superimposed  layers  of  gauze,  to  saturate 
them.  They  are  then  applied  to  the  limb  and  molded 
in  the  same  manner  as  described  in  the  first  method. 

(D)  Again,  the  plaster  of  Paris  roller  bandage, 
having  first  been  made  plastic  by  immersion,  may  be 
cut  in  lengths  to  correspond  to  measurements  of  the 
extremity.  Several  such  lengths  are  superimposed 
and  then  molded  on  the  limb  as  described. 

(E)  Finally,  the  moistened  plaster  bandage  may 
be  molded  directly  on  the  limb  by  playing  the  band- 
age to  and  fro  upon  it,  each  end  of  the  bandage  be- 
ing held  by  an  assistant,  who  grasps  the  successive 
turns  as  they  are  superimposed  (Fig.  48),  the 
surgeon  at  the  same  time  striking  the  bandage 
to  make  it  adhere  to  the  deeper  layer.  The  subse- 
quent steps  are  identical  with  those  mentioned  above. 

This  variety  of  molded  splints  is  made  as  follows : 
Two  pieces  of  canton  flannel,  shaped  to  conform  to 
the  circumference  of  the  fractured  member,  are  sewn 
together  lengthwise  through  their  middle  (Fig.  49), 
in  single  or  double  line  of  stitches,  the  seam  always 
arranged  to  occupy  the  posterior  aspect  of  the  limb. 
One-half  of  the  inner  layer  of  flannel  is  then  passed 
about  the  limb  and  secured,  by  several  stitches  or  by 
adhesive  plaster,  to  the  underlying  dressing  (band- 


Methods  of 
Application 
The  Bavarian 
Splint 


56    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 


■ij!.    48.     Molded    splint    made    by    to    and    fro    passage    of    plaster 
roller    bandage. 


Fig.    49.     Two    pieces    of    flannel    stitched    for    Bavorian    splint. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    57 


age).  Plaster  of  Paris  paste  is  then  applied,  and 
thoroughly  rubbed  into  this  layer  of  flannel.  Before 
the  plaster  has  dried  the  outer  layer  of  flannel  on  the 
same  side,  is  superimposed.  The  two  flannel  layers 
on  the  other  side  are  then  similarly  manipulated. 
When  both  halves  have  set  completely,  they  may  be 
cut  down  in  front,  and  turned  to  either  side,  the 
seam  posteriorly  acting  as  a  hinge,  to  permit  of  an 
inspection  of  the  parts,  after  which  they  are  turned 
back  again  and  securely  held  in  place  with  several 
strips  of  adhesive  plaster,  over  which  turns  of  a 
muslin  bandage  are  passed. 

This  is  another  form  of  molded  plaster  of  Paris 
splint.  A  number  of  strands  of  hemp  are  beaten, 
then  dipped  into  a  paste  of  plaster  of  Paris  and 
spread  out  over  the  limb,  previously  anointed  with 
vaselin.  Additional  plaster  of  Paris  paste  is  rubbed 
into  the  strands  of  hemp,  and  more  of  the  latter  are 
added,  from  time  to  time,  to  impart  the  necessary 
thickness  to  the  splint.  First  an  anterior,  and  then  a 
posterior,  section  is  molded,  and  both  are  held  in 
contact  with  the  limb  by  turns  of  a  muslin  bandage. 
The  latter  is  divided  when  the  splints  have  hardened, 
and  these  are  now  lined  with  non-absorbent  cotton 
and  securely  held  in  place  by  strips  of  adhesive  plas- 
ter and  a  muslin  roller. 

A  length  of  tricot  cylinder  is  filled  with  cotton  or, 
preferably,  strands  of  hemp.  It  is  then  dipped  in  the 
paste  of  plaster  and  thoroughly  kneaded  therein. 
When  completely  impregnated,  it  is  applied  to  the 
part  and  shaped  to  it  by  turns  of  a  muslin  bandage, 
which  holds  it  in  place  while  it  is  hardening.  Like 
the  other  splints,  it  is  subsequently  lined  with  non- 
absorbent  cotton. 


The 

Hemp 

Splint 


The  Tricot 
Molded  Splint 


58    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

This  splint  should  be  made  to  extend  from  the 

Molded  Splint  'fOot  of  the  neck  to  the  elboiv  and  to  embrace  the 

for  Fracture   arm    on     all     but    its     mesial     side.       (I'ig-    50.) 

of  the  With  the  aid  of  such  a  molded  splint,  we  can  attain 

Shoulder  or  complete  immobilization  when  the  splint  is  secured 

"^    to  the  thorax  with  muslin  and  dextrine  bandages. 

The  elbow  is  left  free,  so  that  the  forearm  acts  as  a 


Lateral    view.  Anterior    view. 

Fig.    so.     Plaster    molded    splint    for    humerus    fracture. 


counterextending  factor.  If  the  indications  warrant 
immobilization  of  the  elbow  joint,  the  splint  may  be 
extended  along  the  outer  dorsal  aspects  of  the  fore- 
arm to  the  wrist.  (Figs.  51,  52.) 
Cole's  Splint  Here  we  may  use  a  separate  anterior  and  a  pos- 
terior splint,  or,  as  in  the  "sugar-tong  splint"  of 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    59 


Fig.    51.     Molding    splint    for   fracture    of    humsrus  with   roller 
bandage. 


6o    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 


I'ig.    52.     Molded   splint    for   fracture   of   humerus   suspended   to    dry. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    6i 

Cole,  one  piece  hinged  at  the  elbow.    (Fig.  54,  page 

62.)     This  latter  splint  is  made  by  passing  a  plaster 

of  Paris  bandage  from  the  wrist  along  the  flexor 

aspect  of  the   forearm,  the  latter  being  held  in  a 

position  of  pronation,  and  then,  turning  about  the 

elbow,  the  bandage  covers  the  extensor  surface  of 

the  forearm.     The  extremities  of  the  bandage  are 

held  taut  by  the  surgeon  while  it  is  setting.     The 

dressing  is  held  in  place  by  turns  of  a  muslin. 

This  bandage  is  suitable  for  fractures  in  the  lower  ,     „  ■    1 

Braatzs   Spiral 
portion  of  the  forearm  or  Colles'  fracture.    A  strip    Molded  Splint 

of  gauze  impregnated  with  plaster  of  Paris  paste,  or 
tricot  cylinder  filled  with  plaster  paste,  is  wound 
spirally  about  the  forearm,  beginning  at  the  elbow, 

just   beneath    the 
internal     condyle,  • 

then,   passing  ob- 
liquely   over    the 

Fig.    S3.     Braatz's   spiral   molded   splint  A^XOr     SUrface    of 

for    Colles'    fracture.  ^  ^^  ^      forearm,      it 

turns  about  the  radial  side  of  the  forearm,  passing 
over  the  lower  third  of  the  radius  on  its  dorsal  sur- 
face, and  terminates  at  the  heads  of  the  metacarpal 
bones.  (Fig.  53.)  The  splint  is  finally  lined  with 
non-absorbent  cotton  and  secured  with  turns  of 
muslin  and  starch  bandages. 

Several  layers  of  crinolin,  of  appropriate  length,   -^  ^,  d  S  1'  t 
are  dipped  into  a  paste  of  plaster  of  Paris,  and  are  for  Fracture  of 
then  applied  to  the  dorsum  of  the  forearm,  from  the   the  Forearm 
elbow  to  the  heads  of  the  metacarpal  bones.     The 
forearm  is  allowed  to  rest  on  the  thigh  (Fig.  55,  see 
p.  63)  and  if  the  fracture  be  in  the  lower  end  of  the 
radius  or  ulna,  the  hand  is  sharply  flexed  at  the  wrist, 
grasping  the  knee.     Before  applying  the  splint,  the 


62    PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 


(a)    Passing    loUcr   bandage    to    and    fro. 


(c)    Securing    the    sugar    tongue    splint. 
Fig.    54.     "Cole"    sugar   tongue   splint   for    fracture    of    forearm. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    63 

arm  is  anointed  with  vaselin,  in  order  that  the  mold 
may  be  easily  removed  after  it  has  set.  The  splint 
is  then  lined  with  non-absorbent  cotton,  dusted  with 
dermatol,  and  secured  to  the  forearm,  first  by  ad- 
hesive straps  one  inch  wide,  then  by  muslin  ban- 
dages, and  lastly  by  a  crinolin  bandage.  Instead  of 
the  layers  of  crinolin,  a  roller  bandage  of  plaster  of 


Fig.   55.     Molding  a  dorsal  splint  for  forearm   fracture. 


Paris,  the  width  of  the  forearm,  may  be  run  up  and 
down,  and  molded  to  the  shape  of  the  limb.  (See 
Fig.  48,  page  56.) 

This  splint  is  molded,  in  the  same  manner  as  the 
one  just  described,  about  the  foot,  which  is  to  be  in 
the  right-angled  position.    It  extends  up  the  calf  of 


Gutter  Splint 
for  Fracture  of 
Both  Bones  of 
the  Leg. 


64    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

the  leg;  to  the  flexure  of  the  knee  joint  or  above. 
A  splint  is  alst)  laterally  placed.  {V\g.  56.)  This 
(Stimson's)  si>lint  is  suitable  for  fracture  of  the  leg 
or  injuries  of  the  knee  joint,  when  ambulatory  treat- 
ment is  deemed  inadvisable.  It  is  not  eligible  when 
there  is  any  deformity  that  can  not  be  wholly  cor- 


l'"ig.   56.     Plastci-  of   Paris  Ruttcr  splint    for   fracture  of   one  or   hotli 
bones   of   tile   leg. 


rected  under  anesthesia,  for  the  splint  embraces  but 
half  the  inner  and  outer  aspects  of  the  leg.  When 
dry,  the  splint  is  lined  with  non-absorbent  cotton 
dusted  with  dermatol,  and  held  in  position  by  muslin 
and  crinolin  bandages,  applied  successively. 


CHAPTER    VI 


PLASTER  OF   PARIS   IN    ORTHOPEDIC   SURGERY 


It  was  this  device  as  taught  by  Sayre  that  gave 
the  greatest  impetus  to  the  use  of  plaster  of  Paris  Plaster  of  Paris 
dressings.    The  manner  of  its  apphcation  laid  down  Corset  (Jacket) 
by  him  survives  to  this  day  as  the  chosen  method. 
A  plaster  of  Paris  jacket  may  be  applied  with  the 


I'ig-     57-     Crawling     posture     while     applying     hose     investment     for 
jacket. 

patient  either  in  the  suspended  vertical  position 
(Sayre),  or  in  the  swaying  horizontal,  or  recum- 
bent position. 

Vertical  Suspension. — The  patient  is  stripped  of  Vertical 
all  clothing.  The  body  is  cleaned  with  soap  and  Suspension 
water,  rubbed  with  alcohol,  and  freely  dusted  on 
all  sides  with  talcum,  dermatol,  bismuth,  or  a  mix- 
ture of  these.  While  in  a  position  as  if  crawling,  i. 
e.,  with  the  body's  weight  supported  on  the  hands 
and  knees,  thus  relieving  the  spine  of  any  pressure, 
(Fig.  57),  a  seamless  shirt  or  tricot  hose  is  slipped 
on.    If  the  latter  is  used,  the  upper  end  is  fitted  by 

65     • 


66    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 


slitting  the  hose  in  the  axillary  lines  to  a  depth  suf- 
ficient to  bring  the  ends  over  the  shoulder,  where 
they  may  be  tied,  or  secured  with  a  few  stitches  or  a 
safety  pin.  All  folds  in  the  shirt  are  smoothed  away 
by  drawing  it  down  and  securing  it  snugly  in  the 
perineum  with  a  safety-pin.  The  shirt  or  tricot 
should  be  as  long  again  as  that  part  covering  the 
body.     The  object  of  this  to  be  described  shortly. 


Fig.    58.     Sayre's    suspension    application    of    plaster   jacket. 

The  patient  is  lifted,  with  assistance  if  heavy,  into 
the  suspension  apparatus  of  Say  re.  (Fig.  58.) 
Suspension  apparatus  consists  of  a  curved  iron  cross 
bar  with  notches,  to  which  is  attached  an  adjustable 
leather  head  and  chin  collar  with  straps.  To  a  ring 
in  the  center  of  the  bar  is  hooked  a  pulley,  the  other 
end  of  which  is  secured  either  to  a  pulley  in  the  ceil- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    67 

ing,  at  the  top  of  door  frame,  or  the  top  of  an  iron 
tripod — or  two  ladders  hinged  at  their  upper  ex- 
tremity. By  the  pull  of  the  rope  that  plays  between 
the  two  pulleys  the  apparatus  is  raised  or  lowered. 
With  a  diseased  spine,  the  patient  should  never 
assume,  unsupported,  the  erect  posture.  The 
patient  is  suspended  in  the  apparatus  by  the  chin, 
with  the  arms  extended  and  grasping  the  cross-bar 


Fig.    59.     Use    of    ladders    to    operate    the    suspension    apparatus. 

to  aid  in  the  extension  of  the  spine.  (Fig.  59.)  The 
ropes  that  are  fastened  to  the  cross-bar  and  play 
about  the  pulleys  above,  are  drawn  upon  until  the 
entire  body  sways,  and  the  tips  of  the  toes  touch 
the  floor,  or  the  stool  placed  beneath  so  that  the 
patient's  trunk  is  on  a  level  with  the  arms  of  the 
surgeon  seated  and  applying  the  plaster  bandages. 


68    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

By  no  )iicaiis  is  it  necessary  to  cany  the  extension 
so  far  that  the  feet  arc  off  the  floor.  An  assistant 
grasps  the  legs  to  prevent  the  swaying  of  the  body, 
as  well  as  its  rotation,  and  to  guard  against  the  in- 
advertent flexion  of  the  thighs.  Another  assistant 
controls  the  rope  with  one  hand,  and  with  the  other 
steadies  the  extended  arms  of  the  patient,  so  as  to 
prevent  rotation  of  the  cross-bar. 

All  the  'bony  prominences,  such  as  the  spines  of 
the  ilium,  and  the  gibbus  itself,  and  also  any  very 
decided  hollow,  especially  about  the  waist  line — if 
there  be  much  laterol  curvature  or  lordosis — are 
covered  with  a  thickness  of  piano  felt.  The  piece 
of  felt  over  a  prominence  may  be  fenestrated  so  as 
to  allow  the  knuckle  of  bone  to  engage  in  the  win- 
dow, and  over  this  window  softer  material  may  be 
placed  eventually.  This  is  to  protect  the  promi- 
nences from  pressure,  and  to  fill  in  the  hollows,  also 
that  the  symmetry  of  the  jacket  may  prevent  the 
plaster  from  cracking.  In  each  axilla  felt  or  several 
thicknesses  of  gauze  will  protect  the  skin  from  the 
friction  of  the  edges  of  the  finished  jacket.  These 
pads  are  successively  placed  as  the  turns  of  the  ban- 
dage are  about  to  grasp  them.  It  is  no  longer  the 
practice  to  place  a  pad  over  the  gastric  area  to  make 
allowance  for  the  full  or  empty  stomach. 

If  the  patient  rests  comfortably  in  the  suspended 
position,  so  judged  if  the  head  rests  easily  in  the 
sling,  and  extension  and  not  suspoision  is  practiced 
(the  latter  intending  to  raise  the  feet  from  the  floor 
wrongly  so) ,  the  application  of  the  plaster  of 
Paris  bandages  may  follow.  The  bandages  should 
be  four  inches  wide  for  the  younger  children,  and 
for  older  children,  of  larger  build,  six  inches.  The 
bandages  are  passed  circularly  or  spirally  around 
the  body.     Below  the   bandages  should  reach  the 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    6g 

great  trochanters,  and  above  they  should  pass  under 
the  axilla  and  iirell  over  the  top  of  the  stermwi. 
These  limits  of  the  jacket  must  be  well  borne  in 
mind ;  for  the  commonly  committed  failure  to  ob- 
serve them  is  chiefly  responsible  for  ill-fitting  cor- 
sets. If  too  short  below,  the  jacket  presses  into  the 
abdomen  (Fig.  60),  or  the  latter  bulges  out  beneath 


Fig. 


60.     Heavy    line    shows    correct    extent    of    plaster,    the    light 
outline   the   incorrect. 


the  edge  of  the  plaster ;  if  not  carried  high  enough, 
the  jacket  fails  to  effect  the  necessary  extension  of 
the  spine.  After  the  setting  of  the  plaster  is  com- 
pleted, generally  at  the  expiration  of  a  quarter  of 
an  hour,  the  patient  is  to  be  lifted  out  of  the  swing 
(Fig.  61.)  Being  grasped  by  an  assistant  from  be- 
hind,   his    hands    passing   beneath    the    axillae,    the 


;o    PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 


Fig.     CI.     ^lelliod   of   transporting  i)aticnt   with   jacket   or   spica. 

patient  is  borne  on  the  chest  of  the  assistant,  and  yet 
another  assistant  supports  the  extremities  so  as  to 
avoid  any  liexion  of  thighs,  which  might  indent  or 
crack  the  plaster,  and  is  placed,  temporarily,  in  the 
recumbent  position,  the  head  resting  on  a  small 
pillow.  (Fig.  62.)  Thus  placed,  any  further  hard- 
ening of  the  plaster  is  permitted  before  proceeding 
to  trim  the  I'acket. 


Fig.  62.     Patient  in  bed — rc[iosing  on  pillow  to  permit  jacket  to  dry. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    71 

Trimming  the  Jacket. — In  order  to  allow  flexion  Trimming 
of  the  thighs  on  the  abdomen  a  crescent  of  plaster  the  Jacket 
of  sufficient  size  is  removed  from  each  side,  at  the 
level  of  Poupart's  ligament.  To  allow  adduction  of 
the  arms  a  crescent-shaped  piece  is  cut  from  the 
axillae.  The  bandage  must  not  be  cut  below  the 
sternal  notch,  and  a  tongue  of  plaster  must  be  left 
about  the  symphysis  pubis.  The  jacket  must  be  cut 
on  the  sides  until  it  conforms  to  the  upper  limit  of 
the  great  trochanter.  (Fig.  63.)  The  patient  now 
assumes  the  crawling  attitude  and  the  jacket  is 
trimmed  above,  straight  across  posteriorly  from  the 
upper  limit  of  one  axillary  fold  to  that  of  the  other. 
Below,  the  excess  of  plaster  is  cut  across  posteriorly 
at  such  a  level  that  the  cast  will  not  touch  the  chair 
seat  when  the  patient  is  sitting.  If  there  be  any 
sinuses  leading  into  cold  abscesses,  the  cast  should 
be  fenestrated,  to  admit  of  their  being  dressed.  Any 
small  decubitus  (pressure  sore),  or  the  site  at  which 
one  is  likely  to  form  over  the  gibbosity  may  be 
dressed  with  balsam  of  Peru  under  the  jacket  with- 
out fenestration. 

The  knitted  shirt  or  tricot  hose  extending  beyond 
the  cast  is  drawn  back  over  it  and  stitched  together. 
This  excess  of  hose  not  only  imparts  a  neat  finish 
to  the  jacket,  but  also  prevents  the  rough  cut  edges 
of  the  plaster  from  pressing  into  the  soft  parts. 
When  an  excess  of  shirt  or  tricot  is  not  available, 
the  cast  may  be  covered  with  several  turns  of  a 
crinolin  bandage,  and  the  cut  edges  covered  with 
adhesive  plaster.  If  the  cast  is  to  'be  a  permanent 
one,  it  is  now  completed.  If,  however,  it  is  to  be  a 
removable  one,  it  is  to  be  cut  down  the  front  with 
a  mitre  saw  or  Stilles'  bone  forceps  while  the  trim- 
ming is  being  done.    The  opposing  front  edges  thus 


n    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 


Jacket  with 
Jury-Mast 


fornicd  are  bound  with  adhesive  i)laster  and  are 
fastened  together  with  the  same  material.  For 
long-continued  wear,  the  edges  should  be  bound 
with  leather  or  canvas  provided  wMth  a  row  of  hook- 
lets.  These  are  stitched  on  and  laces  thrown  about 
them.     (Fig.  64.) 

Jacket  with  Jury-Mast. — For  the  cervical  form 
of  Pott's  disease,  as  well  as  such  cases  in  which  the 
disease  is  high  up  in  the  dorsal  vertebrae,  it  is  cus- 
tomar)^  to  incorporate  a  jury-mast  in  the  dorsal  part 
of  the  jacket.     This  latter  device  (as  illustrated  in 


Fig.    Gz-      Method    of    trimming    jacket. 

Fig.  65),  is  a  band  of  steel,  whose  lower  end  has 
pieces  of  tin  attached  at  right  angles  to  facilitate 
its  fixation  in  the  plaster  cast.  Its  upper  end  is  bent 
to  conform  to  the  spine,  and  likewise  in  passing  over 
the  occiput  to  the  vertex  of  the  skull.  (Fig.  65.)  The 
vertical  part  of  the  steel  band  may  be  made  in  two 
parts,  sliding  on  each  other  and  securable  by  screws 
so  that  the  mast  may  be  lengthened  at  will.  To  the 
upper  extremity  of  this  band  of  steel  there  is  at- 
tached a  short  bar  which  plays  on  a  swivel.  From 
either  end  of  the  bar  there  passes  a  piece  of  web- 


PLASTER  OF  PARIS  AND  HOJV  TO  USE  IT    73 


bing  or  leather  strap  around  the  chin  to  support  the 
head,  and  thereby  reheve  the  spine  from  the  pres- 
sure of  the  superimposed  weight  of  the  head.  The 
band  of  steel  should  be  so  bent  as  not  to  touch  the 
spine  or  the  head.  The  degree  of  extension  will  be 
the  greater  the  more  the  steel  band  is  carried  away 
from  the  head. 

Horizontal  Suspension. — When  a  suspension  ap- 


Fig.    64.     Plaster    of   Paris    jacket    provided    with    hooks    for    lacing. 
Note   a   upper  limit;    b  lower  limit;   c  incorrect   lower  limit. 

paratus  is  not  at  hand,  the  patient  may  be  placed  in 
the  horizontal  position,  face  down,  the  body  being 
stretched  between  two  tables.  (Fig.  66.)  The 
shoulders  rest  on  a-  pillow  on  one  table,  and  the 
thighs  on  another.  One  assistant  is  detailed  to  apply 
traction  to  the  thighs,  and  another,  hooking  his 
fingers  in  the  axillae,  exercises  traction  upward.   The 


Horizontal 
Suspension 


74    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

weight  of  the  trunk  effects  a  lordosis,  thereby  over- 
coming any  existing  kyphosis  (gibbus).  The  same 
precautions  are  to  be  observed  as  in  the  vertical 
method,  in  covering  any  bony  prominences.  The 
plaster  bandage  is  passed  in  circular  or  spiral  turns 
around  the  trunk. 

Goldthwait's      Goldtlnvait's  Aletliod.— A  jacket  may  also  be  ap- 
Method 


Fig.   65.     Plaster  of  Paris  corset,  with  a  jury-mast  incorporated. 


plied  with  the  patient  in  a  recumbent  position,  rest- 
ing upon  an  appliance  consisting  of  two  wire  sup- 
ports, on  one  of  which  rests  the  sacrum,  the  other 
being  placed  beneath  the  deformity  (with  pads  in- 
tervening). With  hyperextension,  a  sufficient  lever- 
age is  exerted  to  correct  the  deformity.    The  plaster 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    75 


bandage  passes  about  the  supports  and  includes  the 
pads. 

Horizontal  Alethod  in  Hammock. — In  place  of  the 
tables,  again,  a  hammock  made  of  extra  stout  muslin 
or  canvas  is  suspended  between  two  w^alls.  (Fig.  67.) 
The  patient  is  placed  therein,  face  downwards,  arms 
and  legs  extended.  The  plaster  of  Paris  roller  ban- 
dage, in  its  turns  about  the  body,  includes  the  ham- 
mock. On  the  completion  of  the  bandaging,  the 
excess  of  hammock  is  cut  away.  A  modification  of 
this  consists  in  placing  the  patient  on  his  back  with 
a  support  under  the  pelvis  and  a  pillow  beneath  the 
head.     At  about  the  site  of  the  deformity  a  sling 


Horizontal 
Method  in 
Hammock 


Fig.  66.     Application  of  plaster  of  Paris  corset  in  horizontal  position. 

made  of  stout  muslin  passes.  (Fig.  68.)  The 
greatest  prominence  of  the  projection  is  pro- 
tected by  a  layer  of  saddler's  felt.  The  sling  passes 
to  either  side  of  the  thorax,  to  be  attached  to  the 
horizontal  bar  of  a  suspension  apparatus.  By  rais- 
ing the  bar,  the  counterweight  of  the  body  operates 
towards  effacing  the  deformity.  At  this  particular 
moment  plaster  of  Paris  bandages  may  be  applied, 
including  the  sling,  which  eventually  is  cut  off  at  the 
point  of  emergence  from  the  bandage  on  either  side 
and  the  holes  are  subsequently  covered  by  more 
turns  of  plaster  bandages. 


76    PLASTER  OF  PARIS  AND  IIOW  TO  USE  If 

The  Bradford    j\^q  Bradford  ]""rame  is  similar  in  application  to 
^ramr  the  hammock.    It  is  a  rectangular  frame  constructed 

of  gas  ])ii)e,  over  which  is  stretched  a  piece  of  can- 
vas. The  patient  rests  on  this,  face  down,  arms  ex- 
tended, the  hands  grasping  the  frame  above,  while 
the  feet  may  be  drawn  down  by  an  assistant  (Fig. 
70)  ;  or  each  foot,  with  the  thighs  in  the  abducted 
position,  may  be  secured,  with  traction,  to  the  lower 
part  of  the  frame.  A  slit  is  then  cut  in  the  canvas 
(Fig.  69)   on  each   side  of,  and  parallel  with,  the 


Fig.    67.       Application    of    plaster    of    Paris    corset    by    horizontal 
method   in    hammock. 


body.  Through  these  slits  the  roller  bandage  passes 
in  its  turn  about  the  body,  to  include  the  canvas 
bed.  (Fig.  70.)  The  excess  of  canvas  is  cut  away 
after  the  bandage  is  completed  and  a  few  more 
turns  of  plaster  made. 

Indications. — Every  form  of  Pott's  disease  is  suit- 
able for  a  plaster  jacket — save  adults  in  whom  the 
disease  is  high  up  in  the  spine,  or  where  the  great 
dimensions  of  the  plaster  jacket,  owing  to  the  large 
ness  of  the  individual,  forbid  its  use. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    77 

A  paralysis  from  pressure  of  deformed  spine  is 
often  relieved  forthwith  by  its  use.  Where  there  are 
large  cold  abscesses  accessible  these  had  better  be 
treated  preceding  the  application  of  plaster.  Very 
acute  conditions  with  spasm  and  pain  had  better  be 
given  treatment  in  bed  in  the  horizontal  position 
before  applying  the  jacket. 

A  laced  jacket  is  indicated  at  the  start  in  the  less     Laced 
acute    cases    of    spondylitis,    and    where    extensive     Jacket 
wounds  require  surgical  dressing.    Jackets  are  also 
indicated  in  cases  of  lateral  curvature  to  supplement 


T 
.   I  I 

Fig.   68.     Suspension  in   a  sling  to   permit  application   of   corset. 

gymnastics,  and  for  cases  in  which  the  distorted 
spine  is  painful.  A  plaster  of  Paris  corset  is  also 
indicated  in  fracture  of  the  spine  prior  to  the  per- 
formance of  an  operation,  or  when  operation  is 
contraindicated  and  also  after  an  operation  has 
effectually  reduced  the  fracture,  dislocation,  or  frag- 
ments of  bone  have  been  removed.  In  some  very 
exceptional  cases  of  rachitic  curvature  I  have  also  Rachitic 
applied  a  jacket  with  benefit,  for  it  prevented  the  Curvature 
movements  of  a  very  tender  spine  until  anti-rachitic 
treatment  became  effective. 


7^    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

It  may  at  times  be  necessary  to  extend  the  plaster 
bandage  so  as  to  include  the  hip  in  a  spica  ( Fig. 
71),  as  in  sacroiliac  disease,  or  in  a  complicating 
hip-joint  affection ;  and  if  the  spinal  disease  be  in 


Fig.    69.     Bradford    frame. 

the  upper  cervical  region  the  turns  of  the  plaster 
bandage  should  even  pass  beneath  the  axilla  and 
about  the  shoulders  so  as  to  carry  them  well  back. 


Fig.   70.     Corset  applied   in   Bradford   frame. 

Particulars  About      Particulars  About  the  Jacket. — The  jacket  should 

the  Jacket  weigh  between  one  and  two  pounds,  and  should  be 

of  uniform  thickness  throughout.     If  there  is  any 

decided  acuity  of  the  disease,  it  is  far  better  not  to 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    79 

split  the  jacket,  lest  meddlesome  guardians  remove 
it  too  frequently.  A  well-fitting  and  comfortable 
jacket  may  remain  in  place  for  two  months.  At  the 
expiration  of  this  time  the  condition  of  the  skin  de- 
mands consideration,  and  the  removal  of  the  jacket 
is  necessar}^  for  hygienic  reasons.  Thereafter  it 
may  be  reutilized,  being  provided  with  hooks  and 


Fig.    71.     Combined   corset   and   hip   spica. 

laced,  or  brought  together  with  strips  of  adhesive 
plaster,  and  so  held  in  place. 

The  report  of  any  pain,  or  the  existence  of  an) 
odor,  about  the  jacket  is  indicative  of  an  open 
wound.  This,  in  the  case  of  children,  is  commonly 
caused  by  the  presence  of  a  foreign  body,  playfully 


8.)    PLASTIiR  OF  I\IRIS  .IMJ  llUW  TO  USE  11 

inserted  or  accitlentally  tinding-  its  way  beneath  the 
jacket.  The  exact  location  of  such  a  foreign  body 
is  betrayed  by  the  staining  of  the  plaster  bandage  if 


Fig.    72.     Plaster   crown    with    wiios   altachcJ — a    substitute    for   jury 
mast. 


secretion  is  profuse  or  by  site  of  pain  or  circum- 
scribed odor.    A  window  cut  in  the  jacket  suffices  to 


Fig.    73-      I-orenz    bed. 

remove  the  offending  object  and  permits  the  applica- 
tion of  a  dressing. 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    8i 

A  plaster  jacket  may  be  employed  as  a  mold,  from 
which,  by  filling  the  interior  with  a  mixture  of  plas- 
ter of  Paris,  a  cast  of  the  deformity  can  be  made. 
Over  this  cast  corsets  of  other  material — felt,  wood, 
veneering",  aluminum,  and  celluloid — may,  in  turn; 
be  molded. 

If  a  jury-mast  be  not  obtainable,  a  crown  of  plas- 
ter of  Paris  may  be  passed  about  the  head  and  this 


Fig.    74.     Plaster    of    Paris    jacket    with    figfure-of-eight    turns    about 
the  neck   for  cervical   spondylitis  or  torticollis. 

then  joined  by  two  steel  bands  passing  to  the  plaster 
jacket  and  incorporated  in  its  turns.     (Fig-.  72.) 

In  young  infants  who  are  to  be  carried  about,  a 
plaster  jacket  is  impracticable  because  of  its  weight, 
and  because  it  impedes  the  thoracic  movements.  As 
such  infants  do  not  assume  a  sitting  or  an  erect 
posture,  they  are  best  treated  in  recumbency.     For 


Lorenz  Bed 


82    PLASTER  OP  PARIS  AND  HOW  TO  USE  IT 

this  purpose  the  Lorcnz  bed  is  admirable.  (Fig. 
yT,.)  It  is  a  si)Hnt  molded  to  the  contour  of  the  spine, 
extending  laterally  to  the  posterior  axillary  line. 
Plaster  Collar  When  the  disease  is  in  the  upper  spine,  it  may  be 
and  Jacket  ^loided  about  the  neck  and  head.  It  is  to  he  padded 
with  non-absorbent  cotton,  and  secured  to  the  trunk 
by  turns  of  muslin  and  crinolin  bandages. 


ter    of    Paris    collar. 


When  the  disease  of  the  spine  is  high  up  in  the 
dorsal  region,  or  in  the  lower  cervical,  the  bandages 
may  be  extended  around  the  neck  ( Fig.  74)  ^  i" 
figure-of-eight  turns  ;  or  by  like  turns  the  head  being 
included  may  be  fixed;  or  a  separate  collar  (Fig. 
75)    may   be   made,   inpinging   upon    the   mastoid 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    83 

processes  embracing  the  lower  jaw,  extending  well 
on  to  the  shoulders,  and  resting  upon  the  clavicles. 
These  plastic  investments  for  the  neck  are  indicated 
in  the  correction  of  torticollis,  or  after  resection  of 
the  sterno-mastoid  for  spasmodic  torticollis,  and  for 
fracture  of  the  cervical  spine. 

During  the  period  of  time,  when  non-operative  Torticollis 
measures  are  resorted  to,  in  the  hope  of  correcting 
wry-neck,  the  deviation  of  the  head  dependent  on 
congenital  spastic  contraction  of  the  sterno-mastoid 
muscle,  may  be  overcome  by  repeated  suspension  in 
the  Sayre's  apparatus.  Where  this  can  be  accom- 
plished, the  position  may  be  maintained  by  investing 
the  body  with  a  plaster  of  Paris  jacket  of  light  con- 
struction and  extending  it  so  as  to  pass  about  the 
neck  in  figure-of-eight  turns  (Fig.  74,  page  81),  sup- 
porting the  chin,  anteriorly  extending  up  to  the 
mastoid  processes  and  supporting  the  occiput  pos- 
teriorly, or,  if  the  muscle  be  more  unyielding,  a 
tenotomy  may  be  indicated,  whereafter  the  plaster 
of  Paris  should  also  include  the  head,  encircling 
the  occiput  and  frontal  bone. 

In  the  acquired  form  of  torticollis,  which  can  be 
easily  righted  by  manual  force,  the  head  can  be  re- 
tained in  a  corrected  position  by  placing  about  it  a 
coronet  made  of  plaster  of  Paris  into  which  a  metal 
ring  is  incorporated  (Fig.  76),  by  means  of  a  muslin 
bandage  passing  through  the  ring  and  about  the 
thigh,  traction  is  made  in  a  direction  opposite  to  the 
existing  torticollis.  This  traction  is  carried  to  the 
extent  of  producing  a  torticollis  in  the  opposite  side, 
thereby  overcoming  the  spasm  of  the  affected  side. 

For  the  torticollis  of  cervical  spondylitis  a  well- 
fitting  plaster  of  Paris  corset  with  a  jury-mast  from 


84    PLASTER  OF  PARIS  AA'D  IIOIV  TO  USE  IT 

which  the  head  is  suspended,  is  the  best  form  of 
treatment. 

Conclusion:  Vwnw  the  aforesaid  it  is  apparent 
that  a  plaster  jacket  has  a  wide  range  of  usefulness 
because  of  its  economic  value,  being  available  by  a 
large  number  of  the  afflicted  indigent  poor  who  can 
not  afford  the  expense  of  a  brace. 


Fig.   y6.     Plaster   of   Paris   coronet    witli    riiiR   incorporated   to   aid   in 
correction    of    torticollis. 

Its  purpose  is  solely  to  immobilize  the  spine — in 
no  way  correcting  a  deformity,  but  limiting  any 
aggravation  of  such  deformity.  All  the  while  such 
patients  may  be  alxnit  enjoying  those  hygienic  con- 
ditions conducive  to  a  cure,  which  is  taken  to  mean 
a  fixed  and  deformed  spine  void  of  pain  in  many 
instances.     Under   favorable   conditions   such   end- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    8s 

results  follow  after  wearing  a  jacket  for  a  couple  of 
years  at  least. 

The  Calot  jacket  is  called  after  Dr.  Calot,  who  de-     Calot  Jacket 
vised  it. 

The  patient  is  suspended  in  the  Sayre  apparatus, 
but  if  paralyzed  the  extension  is  undertaken  with  the 
patient  seated  on  a  bicycle  seat  attached  to  a  tripod, 
instead  of  suspension  with  limbs  extended.  Calot 
uses  plaster  bandages  (Fig.  3.  See  p.  5)  freshly 
prepared  by  immersing  the  crinolin  roller  bandage 
in  a  paste  of  plaster  of  Paris,  unraveling  and  re- 
rolling  them  rapidly.  The  tricot  investment  being  in 
place  and  the  bony  points  protected  by  pads  of  felt 
or  cotton,  a  pad  of  non-absorbent  cotton  is  placed 
provisionally  over  the  thorax.  The  plaster  bandages 
are  now  wound  about  the  lower  part  of  the  trunk  as 
in  the  ordinary  plaster  jacket,  but  passing  upward 
the  turns  include  the  shoulder  and  axilla  and  invest 
the  neck  (Fig.  yy)  ;  the  latter  must  be  protected  by 
a  cravatte  of  non-absorbent  cotton  placed  between 
two  layers  of  gauze.  The  turns  about  the  neck  are 
applied  in  figure-eight  fashion.  The  successful  ap- 
plication of  the  bandage  demands  an  absence  of 
anything  like  strands,  exact  adaptation  by  modeling 
about  the  pelvic  and  shoulder  girdle,  and  no  con- 
striction. Calot,  after  the  use  of  the  circular  band- 
ages, gives  additional  strength  to  the  jacket  by  ap- 
plying a  plastron  of  plaster  of  Paris  to  the  thorax 
anteriorly  and  posteriorly.  Such  a  plastron  consists 
of  several  sheets  of  crinolin  previously  measured  to 
fit,  dipped  in  the  cream  of  plaster  and  placed  as 
outlined.  Fach  plastron  is  split  at  its  upper  end 
for  one-third  of  its  length.  These  split  ends  pass 
over  the  shoulder  into  the  axilla.  The  split  ends 
from  in  front  and  ibehind  are  superimposed.     The 


86    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 


lower  ends  of  the  plastron  being  longer  than  the 
trunk,  are  turned  on  themselves  and  worked  in  with 
the  bandage.  The  turns  about  the  neck  are  applied 
circularly  over  the  cotton  cravatte  mentioned  above, 
and  in  conclusion  circular  turns  are  passed  over  the 
plastron,  whereupon  the  modeling  of  the  bandage 
to  the  pelvic  and  shoulder  girdle  begins.  Calot 
recommends   that  cream  of   plaster   be   rubbed   in 


rig.    77.     Temporary   window — Calot  jacket. 

over  all  the  layers  at  the  last  moment.  At  the  ex- 
piration of  fifteen  minutes  the  plaster  has  set.  The 
body  may  be  taken  out  of  suspension  and  placed 
horizontally,  the  neck  resting  on  a  circular  cushion, 
(Fig.  62,  p.  70.) 

Tri)nining. — After  another  half  hour  the  bandage 
is  trimmed  below  to  permit  of  right  angled  flexion 
of  the  thighs  and  nearly  45  degrees  if  patient  is  to  re- 
main in  bed.    In  front  the  bandage  must  reach  over 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    87 

the  pubis.  Above  the  bandage  is  cut  away  so  as  to 
expose  the  shoulders  and  to  permit  of  free  range 
of  motion  a  crescent  is  removed  from  the  axilla. 
Anteriorly  a  small  window  (Fig.  yy)  is  cut  tem- 
porarily to  remove  the  cotton  pad.  The  day  follow- 
ing the  bandage  is  polished  by  first  covering  the 
jacket  with  a  thin  paste  of  plaster  and  rubbing  it 


Fig.    78.     Calot   jacket   completed — large   window. 

down  in  the  act  of  setting.  The  large  window  is  cut 
out  as  outlined  in  Fig.  78.  Hereafter  the  fenestra 
for  gibbus  is  cut  posteriorly.  The  fenestration  to 
be  larger  by  3^  cm.  than  the  area  affected.  (Fig. 
79.)  Beneath  the  edges  of  the  window  small  pieces 
of  cotton  are  wedged.  Over  the  gibbus  itself  suc- 
cessive layers  of  cotton  are  placed  until  they  project 


&S    PLASTER  or  PARIS  AXD  IIOW  TO  USE  IT 

beyond  the  level  of  the  plaster  jacket,  and  they  are 
held  in  place  and  subject  to  a  pressure  by  circular 
turns  of  a  crinolin  bandage.  Each  two  months  ad- 
ditional layers  of  cotton  are  placed  as  the  gibbus 
recedes.  The  large  window  in  front  allows  the 
chest  to  yield  under  pressure  from  behind.  At  the 
expiration  of  each  five  or  six  months  a  new  jacket 
is  applied  for  a  period  of  two  or  three  years,  until 
tenderness  and  subjective  symptoms  have  disap- 
peared and  X-ray  pictures  show  a  betterment  as 
compared  with  the  start.  Where  disease  involves 
the   upper  vertebrse   the  plaster  must   include   the 


Fig.     79.     Tenestra     over    gibbus    in     Calot    jacket. 

head.  After  due  protection  of  the  head  and  neck 
by  compresses  of  cotton,  the  plaster  in  turns  of 
figure  eight  pass  about  the  head,  suspended  not  in 
the  leather  sling,  but  a  muslin  sling,  which  remains 
incorporated  in  the  bandage.  (Fig.  80.)  Subse- 
quently protruding  ends  of  the  sling  are  cut  away. 
Here,  too,  Calot  recommends  plastrons  in  front 
from  the  chin,  passing  round  down  the  neck,  under 
the  axilla  and  posteriorly  passing  from  the  vertex 
over  the  shoulders  beneath  the  axilla.  In  other  re- 
spects the  bandage  is  put  on  as  described.  The 
trinnning  of  the  bandage  for  disea.se  of  higher  ver- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    Sg 


tebrse  implies  a  cutting  away  of  the  plaster  about 
the  forehead  so  that  a  collar  touches  the  chin  and 
supports   the   occiput.     (Fig.    8i.) 

A  plaster  of  Paris  spica  passing  about  the  lower 
thorax  and  extending  within  a  few  inches  of,  and 
at  times  including,  the  knee  joint,  is  an  effective 
way  of  immobilizing  the  diseased  hip  joint.  (Fig. 
83.)     The  spica  is  not  to  be  applied,  however,  until 

i 


Fig.    80.     Calot    jacket    for 
disease  "upper  spine." 


Fig.    81.     Calot    jacket    for 
disease  in  upper  spine  trimmed. 


flexion  and  abduction  deformities  have  been  over- 
come by  extension  with  weights  while  in  bed.  The 
presence  of  a  large,  cold  abscess,  or  sinuses  leading 
into  the  bone  or  joint  do  not  contraindicate  the  use 
of  a  plaster  of  Paris  spica.  Even  if  it  be  desirable  to 
apply  some  form  of  brace,  or  traction  splint,  the 
plaster   spica  may  be   retained,   provided   the   ten- 


Hip  Joint 
Disease 


90    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

dency  to  flexion  and  abduction  are  not  marked. 
When  sole  reliance  for  fixation  is  placed  upon  the 
spica,  the  immobilized,  diseased  side  should  be 
kept  from  the  ground  by  the  use  of  crutches,  and  a 
patten  is  to  be  worn  on  the  shoe  of  the  healthy 
limb.  (Fig.  82.)  On  the  whole,  it  must  be  said,  that 
the  plaster  spica,  however,  well  applied,  is  a  hulkv 


Fig.    82.     Method    of    walking    with    plaster    in    hip    disease. 

and  unclean  means  of  treating  hip  joint  disease,  as 
compared  with  some  form  of  metal  splint.  As  a  word 
of  warning,  it  should  never  occur  to  anyone  to  ap- 
ply the  plaster  spica  in  order  to  correct  a  deformity. 
Application  of  the  Hip  Spica. — The  method  of 
applying  a  plaster  hip  spica,  described  in  fractures 
of  the  thigh,  is  equally  applicable  in  hip  joint  dis- 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    91 

ease.  The  great  essential  in  the  appHcation  of  plas- 
ter bandages  about  the  pelvis  is  to  have  the  shoul- 
ders resting  on  a  support  (pillow),  and  the  pelvis 
supported  on  a  rest — -beneath  the  sacrum,  as  de- 
scribed on  p.  34,  Fig.  22.  The  lower  extremities 
should  be  clear  of  the  table. 

Sacro  Iliac  Joint  Disease. — The   spica   used   for 


Fig.   83.     Calot  jacket  with   extension  of  cast  to  include  hip  in  joint 
disease. 


hip  disease  should  be  carried  up  to  the  axilla.  Fol- 
lowing Calot's  suggestion,  a  large  window  may  be 
cut  in  front.      (Fig.  83.) 

An  effusion  of  serum  or  blood  in  the  knee  joint. 
of  traumatic  or  infectious  origin   (gonorrhoea,  tu-  ^"_^^  Joint 
berculosis),  can  very  often  be  rapidly  dispelled  by 
the  absolute  immobilization  afforded  by  a  plaster 


Disease 


92    PLASTER  OF  P.IRIS  AND  HOW  TO  USE  IT 

cast,  investing  the  tliigli,  extending  as  high  as  the 
gluteal  fold  posteriorly,  and  at  times  reaching  up 
to  pouparts  ligament  anteriorly,  thus  not  inter- 
fering with  liexion  at  the  hip  joint  and  prevent- 
ing a  sitting  posture,  of  course,  including  the  knee 
joint,  and  extending  down  the  leg  helow  the  calf. 
A  cast  of  the  same  extent  is  necessary  in  tubercu- 
lous disease  of  the  knee  joint,  but  not  until  the 
flexion  deformity  has  been  overcome  by  gradual 
extension,  with  weights  and  pulleys.  Some  author- 
ities commend  a  correction  under  anesthesia.  The 
knee  joint  immobilized  in  the  cast  (of  light  con- 
struction) must  not  support  the  superimposed 
weight  of  the  body,  therefore  crutches  are  to  be 
used  or  the  knee,  encased  in  plaster  of  Paris,  is 
suspended  in  the  Thomas  splint  for  knee  joint  dis- 
ease, and  a  patten  to  he  worn  on  the  shoe  of  the 
health  side.  With  a  patten  and  crutches  the 
Thomas  splint  may  be  dispensed  with  solely  rely- 
ing on  the  plaster  cast. 
Ankle  Joint  In  all  affections  of  the  ankle,  there  is  a  great 
Disease  tendency  for  the  foot  to  assume  a  position  of  equi- 
nus  combined  at  times  with  eversion  (valgus).  To 
forestall  this,  the  foot  must  very  early  be  placed  in 
a  plaster  of  Paris  cast,  in  a  position  at  right  angles 
to  the  leg.  (Fig.  86,  p.  94.)  Where  there  is  much 
spasm  of  the  tendo  Achilles,  this  may  be  overcome 
by  the  administration  of  an  anesthetic,  and  if  there 
be  still  some  difficulty,  a  subcutaneous  tenotomy 
must  be  resorted  to  before  applying  the  plaster  cast. 
The  cast  should  not  merely  invest  the  ankle,  but 
should  be  carried  up  the  leg  to  the  condyles  of  the 
tibia  as  practiced  in  fractures  of  the  ankle  joint.  If 
allowed  to  terminate  just  below  the  calf  the  edge  of 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    93 

cast  will  work  its  way  into  the  muscles  of  the  leg. 
(Fig.  84.) 

~  The   rigid   flat   foot,   with   spasm   of    the    tendo  Flat  Foot 
Achilles  and  lack  of  mobility  of  the  smaller  artic- 
ulations, and  abduction  and  eversion  in  the  medio- 


Fig.   84.     ^\'rong  plaster  cast. 
Demonstrating    cast    cutting 
into    flesli.. 


Fig.   85.      Wrong  knee   splint. 
Demonstrating    cast    cutting 
into   flesh. 


tarsal  articulation,  calls  for  a  correction  which  alone 
can  be  maintained  by  a  plaster  of  Paris  dress- 
ing. To  effect  a  correction  of  a  rigid  flat  foot,  it 
is  necessary  to  administer  an  anesthetic  and  man- 
ually force  the  foot  into  an  exaggerated  adducted 
(varus)  position.  It  is  thus  maintained  by  a  plas- 
ter of  Paris  dressing,  which  extends  up  the  leg  be- 


94    PLASTER  OF  PARIS  AND  HOW  TO  USE  IT 

yond  the  calf,  preferably  embracing  the  condyles. 
This  plaster  cast  remains  on  for  four  weeks.  For 
the  first  three  weeks  the  patient  occupies  the  recum- 
bent posture;  thereafter  he  may  walk  about  with 
crutches.  At  the  expiration  of  the  fourth  week  the 
dressing  is  removed  and  a  plaster  mold  made,  either 
from  the  dressing  or  directly  from  the  foot  in  its 


!•'!};.     86.     Holding    ankle    in    riglit    angle    position — cast    setting. 

corrected  position.  A  sheet  of  .steel  is  then  ham- 
mered to  conform  to  the  plaster  mold,  on  its  plantar 
surface,  as  far  forward  as  the  head  of  the  first 
metatarsal  bone,  and  to  pass  obliquely  outwards 
back  of  the  heads  of  the  metatarsal  bones,  to  the 
cuboid,  the  posterior  limit  of  this  splint  correspond- 
ing to  the  middle  of  the  os  calcis.  On  the  inner  as- 
pect of  the  cast  the  splint  is  hammered  out  in  a 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    95 


semi-ellipse  extending  to  the  internal  malleolus.  On 
the  outer  aspect  a  tongue  of  metal  is  hammered 
out  as  a  guide  to  prevent  the  splint  from  slipping. 
This  accurately  fitted  splint,  thus  hammered  out 
over  the  plaster  mold,  is  placed  in  the  shoe,  and, 
acting  as  a  lever,  it  forces  the  foot  into  the  correct 
position. 


Fig.    87.   Lorenz  spica  for    unilateral  congenital  dislocation  of    the  hip. 

Of  recent  date  the  teaching  has  gained  ground 
to  apply  plaster  of  Paris  dressings  to  the  members 
rendered  flaccid  by  infantile  palsy  and  forestall  the 
contractures.  To  be  effective  such  plaster  casts 
should  be  applied  very  early  in  this  disease,  as  soon' 
as  the  regressive  stage  has  been  reached.  Such 
plaster  casts  constitute  a  tentative  treatment  prior  to 
the  performance  of  an  athrodesis  or  facilitating  the 
execution  of  a  tendo-plasty  eventually. 


Infantile 
Paralysis 


96    PLASTER  OF  PARIS  AXD  1 1  Oil'  TO  USE  IT 

Congenital         Que  of  the  essentials  is  the  successful  treatment 

P  of  a  congenital  dislocation  of  the  hip  is  the  appli- 

Dislocation  .  *  „  ,-    ■        ,  .  •         ,  •  ,      , 

cation  of  a  well-httnig  hip  spica  in  zchicli  the  pa- 
tient walks  about.  An  X-ray  picture  is  first  taken 
as  a  guide  to  the  location  of  the  head  of  the  femur. 
Then  follows  a  reduction  of  the  head  into  the  acet- 
abulum under  anesthesia,  in  which  it  is  maintained 
by  abducting  the  limb.  In  this  abducted  position 
the  unilateral  or  bilateral  spica  is  applied,  according 
as  the  dislocation  has  been  on  one  or  on  both  sides. 
(Figs.  8/  and  88.)  In  addition  to  the  abduction, 
the  limb  is  slightly  flexed  and  rotated  in.  The  spica 
should  preferably  pass  well  up  on  tlic  thorax, 
though  this  is  by  no  means  absolutely  necessary. 
Its  upper  limit  may  reach  the  floating  ribs.  Event- 
ually this  may  be  cut  down  in  front  beneath  the 
umbilicus.  It  should  not  unnecessarily  extend  be- 
low the  knee,  in  order  not  to  interfere  with  com- 
fort in  walking.  (Fig.  89.)  The  plaster  cast  remains 
on  at  least  six  weeks.  At  the  expiration  of  this  time 
it  is  removed.  If  a  radiograph  then  made  shows  the 
head  of  the  femur  in  the  acetabulum,  the  degree  of 
abduction  is  lessened  gradually  and  another  cast 
applied  in  this  corrected  position,  the  adduction  be- 
ing increased  with  additional  inward  rotation  of  the 
foot.  All  the  time  that  the  cast  is  on,  the  patient 
walks  alxiut,  thus  aiding  by  this  pressure,  in  forc- 
ing the  head  into  the  acetabulum  and  in  shaping 
the  latter.  After  the  removal  of  the  last  cast,  a  hin 
splint  is  to  be  worn  for  some  months. 
Club  Foot  Yhe  deformity  known  as  club  foot,  if  treated  im- 
mediately after  birth,  and  persistently,  can  be  whol- 
ly corrected  by  the  use  of  plaster  of  Paris  dress- 
ings, W'ithin  a  year  or  two.  It  is  necessary,  by  a 
process  of  manipulations,  as  in  modeling,  to  bring 


PLASTER  OF  PARIS  AND  HOW  TO  USE  IT    97 

the  foot  from  its  equinus  position  into  that  of  a 
right  angle  with  the  leg  and  to  overcome  the  ad- 
duction (varus)  and  inward  rotation.  When  these 
have  been  corrected  a  plaster  of  Paris  cast  is  made 
to  invest  the  foot,  extending  up  the  leg  to  the  con- 
dyles of  the  tibia.  Great  care  must  be  taken  in 
padding  the  bony  prominences  with  non-absorbent 
cotton  to  prevent  pressure  sores.     The  best  guar- 


Fig.     88.     Bilateral     congenital     dislocation     corrected     with     Lorenz 
spica. 

antee  against  decubitus,  is  a  thorough  reduction  of 
all  the  abnormal  positions  that  occasion  the  prom- 
inences. If  the  deformity  cannot  be  wholly  cor- 
rected at  the  first  sitting  it  is  remedied  after  the 
removal  of  the  cast  at  the  expiration  of  two  or  three 
weeks.  With  each  renewal  of  the  cast  another  at- 
tempt is  made  to  better  the  position  of  the  foot.  This 


INDEX 


A 
Adjuvants,    chemical,    9. 

Alum,    9. 

Salt,   9. 
Ambulatory  cast.   46. 
Ankle 

Fracture.    40. 

Joint,    92. 
Aj-plication   of   Plaster,    21. 

B 
Bandages,  "  Ideal. "10. 
Application    of    Plaster,    21. 

Lalot,    -5. 

Commercial,   4. 

Hand-made,    2. 

Wire,     4,    6. 
Bavarian    splint,     55. 
Bradford  frame.   76,   7S. 
Braatz  splint,   61. 

C 

Calot  bandage,   5. 
Cast 

Ambulatory,    46. 

Removal  of,   15,   31. 

Replacement  of,  19. 

Splitting    of,    19. 
Coles   splint    (sugar   tong),    62. 
Collar   plaster,    82. 
Colles_  fracture,    29. 
Containers  tin,   3. 
Club  foot,   96. 

Wolffs  method,  98. 
Compound  splint,   47. 
Congenital    hip,    94. 
Corset.   65. 

Bradford    frame,    76.    78. 

Calot,  85.  89. 

Goldthwait  method,  74. 

Plorizontal   method,  75. 

.sayres,     65.     72. 

Trimming.  71. 

Vertical    method,    66. 


Dextrine    bandage. 
Disease 

Ankle  joint,  92. 

Hip  joint,  94. 

Knee    ioint,    91. 

SaGro-Iliac.  91. 


Fenestrated   plaster   casts,    43. 

Flat   foot,   93. 

Fractures 

Ankle   joint,   40. 

Carpal,  30 

Colles,    29. 


Compound.   43. 

Elbow,  28. 

Femur   fshaft),  36. 

Foot,   42. 

Forearm,    25,    61. 

Humerus,   26. 

Hip  joint,   33. 

Knee  joint,    37. 

Metacarpal,    30. 

Olecranon,   47. 

Patella.   46. 

Thumb.   2!j. 

Tibia,   38. 
Fraying  of  bandage,  9. 
Frieberg's    method,    9. 


Gigli    saw,    16. 
Goldthwait  method. 
Gutter  splint,   63. 

H 

Hemp    splirt,    57. 
Hip   rest,   35. 
Hip 

Fracture,   35. 

Joint  disease.  89. 

Spica,  33,  34. 
History,   1. 


Infantile  paralysis,  93. 

J 
Jacket,   65. 
Jurj-   mast,   72. 

K 
Knee  joint 
Disease,  91. 
Fracture,  37. 


Lorenz 
Bed,    80. 
Spica,   96. 


M 


Massage,    11. 
Materials,    1. 

Cotton,    2. 

Crinoline,    2. 

Deimel.     6. 

Dextrine,   2. 

Flax,   2. 

Flannel,   2. 

Gauze.    2. 

Hemp,    2. 


INDllX. 


lute.   2. 

Muslin,    2. 

Sail   cloth,   6,   2. 

Straw,   2. 

Tricot,   2. 
Mitre  saw,  18. 
Mokled  ::iiliiits,  51. 

O 

( )rthoi>e<lics,   65. 


Piiralysis,  Ischemic,  23. 
Paralysis,  liifantik-,  ii3. 
Plaster.    Raiidacre 

(.'onliiiuity,   13. 

I'ractures.    21. 

(ieneral   cinisiiit-rations, 

Precautious.   10. 

Removal    of.    1.'.,   31. 

Sections.    13. 
Posture,    73. 

Precautions.   9. 

Protection,    skin,   f>. 

Protection,   soiling,   6. 

R 

N'achi'.ic  curvature.  77. 
Refuse,   dis-iiosal    of,   15. 
Removal,   bandage,  15,   31. 
Removal,    plaster,    14. 

Suear.   15. 

Suit.    15. 
Rci>lacjmcnt,    19. 


Sacro-Iliac  disease,  01. 
Savres  suspension,  66. 
Saw 

Cigli,  16. 

Mitre.    18. 
Sections,    plaster,    13. 


Shear.s,    Slilles.    19. 
Spica 

ilip,  34.  ne. 

I.orenz.   96. 
Shoulder.    27. 
Thumh.  30. 
Splints 

.Vmhulatory.   46. 
I'.avarian.    5.">. 
IJraatz's.   61. 
foles.    61. 
Compound.    47. 
Tenestrated,  43. 
Cutter,   63. 
Heated.   .[10. 
Hemp,   57. 
I.orenz,   .SI. 
Molded.   51. 
Sepmente<l,   48. 
Sugar  tonjj.  47. 
Suspendeil.   4H. 
Tricot,    57. 


Toilet.   14. 
Torticollis,  83.  84. 
Tricot-hose,    3"'. 
Trimming,   corset,   88. 


\'a.ielinc-.   K'. 

\'enecring.   47. 

W" 

Wire  Bandage, 
Wolff 

Clulvfoot.  OS 

4. 
X 

X-ray 

C  alot   jacket. 
Congenital    1 
I"ractures,    3 

8'^. 
di>, 

06. 

